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The experiences of health and illness, death and dying, the normal and the pathological have always been an integral par
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LITERATURE AND MEDICINE
The experiences of health and illness, death and dying, the normal and the pathological have always been an integral part of literary texts. This volume considers how the two dynamic fields of literature and medicine have crossed over, and how they have developed alongside one another. It asks how medicine, as both science and practice, shapes the representation of illness and transforms literary form. It considers how literary texts across genres and languages of disease have put forward specific conceptions of medicine and impacted its practice. Taking into account the global, multilingual, and multicultural contexts, this volume systematically outlines and addresses this double-sidedness of the literature–medicine connection. Literature and Medicine covers a broad spectrum of conceptual, thematic, theoretical, and methodological approaches that provide a solid foundation for understanding a vibrant interdisciplinary field. . is Associate Professor of French Studies and Medical Humanities at the University of St Gallen. Her area of expertise is death, dying and mourning in twentieth and twenty-first-century literature, philosophy and film. - is Professor of British Cultural and Literary Studies at the University of Vienna and specializes in Medical Humanities, adaptation, transmediality and (neo-)Victorianism.
Published online by Cambridge University Press
Cambridge Critical Concepts focuses on the important ideas animating twentiethand twenty-first-century literary studies. Each concept addressed in the series has had a profound impact on literary studies, as well as on other disciplines, and already has a substantial critical bibliography surrounding it. This series captures the dynamic critical energies transmitted across twentieth- and twenty-first-century literary landscapes: the concepts critics bring to reading, interpretation and criticism. By addressing the origins, development and application of these ideas, the books collate and clarify how these particular concepts have developed, while also featuring fresh insights and establishing new lines of enquiry. Cambridge Critical Concepts shifts the focus from period- or genre-based literary studies of key terms to the history and development of the terms themselves. Broad and detailed contributions cumulatively identify and investigate the various historical and cultural catalysts that made these critical concepts emerge as established twenty-first-century landmarks in the discipline. The level will be suitable for advanced undergraduates, graduates and specialists, as well as for those teaching outside their own research areas, and will have cross-disciplinary relevance for subjects such as history and philosophy. Titles in the Series Law and Literature Edited by University of Western Australia Time and Literature Edited by . University of Ottawa The Global South and Literature Edited by - University of Tu¨bingen Trauma and Literature Edited by . The College at Brockport, State University of New York Food and Literature Edited by . San Francisco State University Animals, Animality, and Literature Edited by , and Florida State University, University of Montreal
Published online by Cambridge University Press
Terrorism and Literature Edited by . San Diego State University Climate and Literature Edited by - University of Surrey Orientalism and Literature Edited by . SOAS, University of London Decadence and Literature Edited by and Goldsmiths, University of London and Hunter College Affect and Literature Edited by University of Cambridge Sound and Literature Edited by King’s College London Magical Realism and Literature Edited by and University of Cambridge and Wheaton College, Illinois Surrealism Edited by University of Melbourne Globalization and Literary Studies Edited by University of Nottingham War and Literary Studies Edited by - and University of Southern Denmark and University of New South Wales Diaspora and Literary Studies Edited by Clemson University, South Carolina Technology and Literature Edited by University of Toronto Literature and Medicine Edited by . and - University of St Gallen and University of Vienna
Published online by Cambridge University Press
Published online by Cambridge University Press
LITERATURE AND MEDICINE ANNA M. ELSNER University of St Gallen
MONIKA PIETRZAK-FRANGER University of Vienna
Published online by Cambridge University Press
Shaftesbury Road, Cambridge , United Kingdom One Liberty Plaza, th Floor, New York, , USA Williamstown Road, Port Melbourne, , Australia –, rd Floor, Plot , Splendor Forum, Jasola District Centre, New Delhi – , India Penang Road, #-/, Visioncrest Commercial, Singapore Cambridge University Press is part of Cambridge University Press & Assessment, a department of the University of Cambridge. We share the University’s mission to contribute to society through the pursuit of education, learning and research at the highest international levels of excellence. www.cambridge.org Information on this title: www.cambridge.org/ : ./ © Cambridge University Press & Assessment This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press & Assessment. First published A catalogue record for this publication is available from the British Library Library of Congress Cataloging-in-Publication Data : Elsner, Anna Magdalena, - editor. | Pietrzak-Franger, Monika, editor. : Literature and medicine / edited by Anna M. Elsner, Monika Pietrzak-Franger. : Cambridge ; New York, NY : Cambridge University Press, . | Series: Cambridge critical concepts | Includes bibliographical references and index. : (print) | (ebook) | (hardback) | (paperback) | (epub) : : Literature and medicine. | Medicine in literature. | Health in literature. : . (print) | .M (ebook) | ./–dc/eng/ LC record available at https://lccn.loc.gov/ LC ebook record available at https://lccn.loc.gov/ ---- Hardback Cambridge University Press & Assessment has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
Published online by Cambridge University Press
LITERATURE AND MEDICINE
The experiences of health and illness, death and dying, the normal and the pathological have always been an integral part of literary texts. This volume considers how the two dynamic fields of literature and medicine have crossed over, and how they have developed alongside one another. It asks how medicine, as both science and practice, shapes the representation of illness and transforms literary form. It considers how literary texts across genres and languages of disease have put forward specific conceptions of medicine and impacted its practice. Taking into account the global, multilingual, and multicultural contexts, this volume systematically outlines and addresses this double-sidedness of the literature–medicine connection. Literature and Medicine covers a broad spectrum of conceptual, thematic, theoretical, and methodological approaches that provide a solid foundation for understanding a vibrant interdisciplinary field. . is Associate Professor of French Studies and Medical Humanities at the University of St Gallen. Her area of expertise is death, dying and mourning in twentieth and twenty-first-century literature, philosophy and film. - is Professor of British Cultural and Literary Studies at the University of Vienna and specializes in Medical Humanities, adaptation, transmediality and (neo-)Victorianism.
Published online by Cambridge University Press
Cambridge Critical Concepts focuses on the important ideas animating twentiethand twenty-first-century literary studies. Each concept addressed in the series has had a profound impact on literary studies, as well as on other disciplines, and already has a substantial critical bibliography surrounding it. This series captures the dynamic critical energies transmitted across twentieth- and twenty-first-century literary landscapes: the concepts critics bring to reading, interpretation and criticism. By addressing the origins, development and application of these ideas, the books collate and clarify how these particular concepts have developed, while also featuring fresh insights and establishing new lines of enquiry. Cambridge Critical Concepts shifts the focus from period- or genre-based literary studies of key terms to the history and development of the terms themselves. Broad and detailed contributions cumulatively identify and investigate the various historical and cultural catalysts that made these critical concepts emerge as established twenty-first-century landmarks in the discipline. The level will be suitable for advanced undergraduates, graduates and specialists, as well as for those teaching outside their own research areas, and will have cross-disciplinary relevance for subjects such as history and philosophy. Titles in the Series Law and Literature Edited by University of Western Australia Time and Literature Edited by . University of Ottawa The Global South and Literature Edited by - University of Tu¨bingen Trauma and Literature Edited by . The College at Brockport, State University of New York Food and Literature Edited by . San Francisco State University Animals, Animality, and Literature Edited by , and Florida State University, University of Montreal
Published online by Cambridge University Press
Terrorism and Literature Edited by . San Diego State University Climate and Literature Edited by - University of Surrey Orientalism and Literature Edited by . SOAS, University of London Decadence and Literature Edited by and Goldsmiths, University of London and Hunter College Affect and Literature Edited by University of Cambridge Sound and Literature Edited by King’s College London Magical Realism and Literature Edited by and University of Cambridge and Wheaton College, Illinois Surrealism Edited by University of Melbourne Globalization and Literary Studies Edited by University of Nottingham War and Literary Studies Edited by - and University of Southern Denmark and University of New South Wales Diaspora and Literary Studies Edited by Clemson University, South Carolina Technology and Literature Edited by University of Toronto Literature and Medicine Edited by . and - University of St Gallen and University of Vienna
Published online by Cambridge University Press
Published online by Cambridge University Press
LITERATURE AND MEDICINE ANNA M. ELSNER University of St Gallen
MONIKA PIETRZAK-FRANGER University of Vienna
Published online by Cambridge University Press
Shaftesbury Road, Cambridge , United Kingdom One Liberty Plaza, th Floor, New York, , USA Williamstown Road, Port Melbourne, , Australia –, rd Floor, Plot , Splendor Forum, Jasola District Centre, New Delhi – , India Penang Road, #-/, Visioncrest Commercial, Singapore Cambridge University Press is part of Cambridge University Press & Assessment, a department of the University of Cambridge. We share the University’s mission to contribute to society through the pursuit of education, learning and research at the highest international levels of excellence. www.cambridge.org Information on this title: www.cambridge.org/ : ./ © Cambridge University Press & Assessment This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press & Assessment. First published A catalogue record for this publication is available from the British Library Library of Congress Cataloging-in-Publication Data : Elsner, Anna Magdalena, - editor. | Pietrzak-Franger, Monika, editor. : Literature and medicine / edited by Anna M. Elsner, Monika Pietrzak-Franger. : Cambridge ; New York, NY : Cambridge University Press, . | Series: Cambridge critical concepts | Includes bibliographical references and index. : (print) | (ebook) | (hardback) | (paperback) | (epub) : : Literature and medicine. | Medicine in literature. | Health in literature. : . (print) | .M (ebook) | ./–dc/eng/ LC record available at https://lccn.loc.gov/ LC ebook record available at https://lccn.loc.gov/ ---- Hardback Cambridge University Press & Assessment has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
Published online by Cambridge University Press
LITERATURE AND MEDICINE
The experiences of health and illness, death and dying, the normal and the pathological have always been an integral part of literary texts. This volume considers how the two dynamic fields of literature and medicine have crossed over, and how they have developed alongside one another. It asks how medicine, as both science and practice, shapes the representation of illness and transforms literary form. It considers how literary texts across genres and languages of disease have put forward specific conceptions of medicine and impacted its practice. Taking into account the global, multilingual, and multicultural contexts, this volume systematically outlines and addresses this double-sidedness of the literature–medicine connection. Literature and Medicine covers a broad spectrum of conceptual, thematic, theoretical, and methodological approaches that provide a solid foundation for understanding a vibrant interdisciplinary field. . is Associate Professor of French Studies and Medical Humanities at the University of St Gallen. Her area of expertise is death, dying and mourning in twentieth and twenty-first-century literature, philosophy and film. - is Professor of British Cultural and Literary Studies at the University of Vienna and specializes in Medical Humanities, adaptation, transmediality and (neo-)Victorianism.
Published online by Cambridge University Press
Cambridge Critical Concepts focuses on the important ideas animating twentiethand twenty-first-century literary studies. Each concept addressed in the series has had a profound impact on literary studies, as well as on other disciplines, and already has a substantial critical bibliography surrounding it. This series captures the dynamic critical energies transmitted across twentieth- and twenty-first-century literary landscapes: the concepts critics bring to reading, interpretation and criticism. By addressing the origins, development and application of these ideas, the books collate and clarify how these particular concepts have developed, while also featuring fresh insights and establishing new lines of enquiry. Cambridge Critical Concepts shifts the focus from period- or genre-based literary studies of key terms to the history and development of the terms themselves. Broad and detailed contributions cumulatively identify and investigate the various historical and cultural catalysts that made these critical concepts emerge as established twenty-first-century landmarks in the discipline. The level will be suitable for advanced undergraduates, graduates and specialists, as well as for those teaching outside their own research areas, and will have cross-disciplinary relevance for subjects such as history and philosophy. Titles in the Series Law and Literature Edited by University of Western Australia Time and Literature Edited by . University of Ottawa The Global South and Literature Edited by - University of Tu¨bingen Trauma and Literature Edited by . The College at Brockport, State University of New York Food and Literature Edited by . San Francisco State University Animals, Animality, and Literature Edited by , and Florida State University, University of Montreal
Published online by Cambridge University Press
Terrorism and Literature Edited by . San Diego State University Climate and Literature Edited by - University of Surrey Orientalism and Literature Edited by . SOAS, University of London Decadence and Literature Edited by and Goldsmiths, University of London and Hunter College Affect and Literature Edited by University of Cambridge Sound and Literature Edited by King’s College London Magical Realism and Literature Edited by and University of Cambridge and Wheaton College, Illinois Surrealism Edited by University of Melbourne Globalization and Literary Studies Edited by University of Nottingham War and Literary Studies Edited by - and University of Southern Denmark and University of New South Wales Diaspora and Literary Studies Edited by Clemson University, South Carolina Technology and Literature Edited by University of Toronto Literature and Medicine Edited by . and - University of St Gallen and University of Vienna
Published online by Cambridge University Press
Published online by Cambridge University Press
LITERATURE AND MEDICINE ANNA M. ELSNER University of St Gallen
MONIKA PIETRZAK-FRANGER University of Vienna
Published online by Cambridge University Press
Shaftesbury Road, Cambridge , United Kingdom One Liberty Plaza, th Floor, New York, , USA Williamstown Road, Port Melbourne, , Australia –, rd Floor, Plot , Splendor Forum, Jasola District Centre, New Delhi – , India Penang Road, #-/, Visioncrest Commercial, Singapore Cambridge University Press is part of Cambridge University Press & Assessment, a department of the University of Cambridge. We share the University’s mission to contribute to society through the pursuit of education, learning and research at the highest international levels of excellence. www.cambridge.org Information on this title: www.cambridge.org/ : ./ © Cambridge University Press & Assessment This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press & Assessment. First published A catalogue record for this publication is available from the British Library Library of Congress Cataloging-in-Publication Data : Elsner, Anna Magdalena, - editor. | Pietrzak-Franger, Monika, editor. : Literature and medicine / edited by Anna M. Elsner, Monika Pietrzak-Franger. : Cambridge ; New York, NY : Cambridge University Press, . | Series: Cambridge critical concepts | Includes bibliographical references and index. : (print) | (ebook) | (hardback) | (paperback) | (epub) : : Literature and medicine. | Medicine in literature. | Health in literature. : . (print) | .M (ebook) | ./–dc/eng/ LC record available at https://lccn.loc.gov/ LC ebook record available at https://lccn.loc.gov/ ---- Hardback Cambridge University Press & Assessment has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
Published online by Cambridge University Press
LITERATURE AND MEDICINE
The experiences of health and illness, death and dying, the normal and the pathological have always been an integral part of literary texts. This volume considers how the two dynamic fields of literature and medicine have crossed over, and how they have developed alongside one another. It asks how medicine, as both science and practice, shapes the representation of illness and transforms literary form. It considers how literary texts across genres and languages of disease have put forward specific conceptions of medicine and impacted its practice. Taking into account the global, multilingual, and multicultural contexts, this volume systematically outlines and addresses this double-sidedness of the literature–medicine connection. Literature and Medicine covers a broad spectrum of conceptual, thematic, theoretical, and methodological approaches that provide a solid foundation for understanding a vibrant interdisciplinary field. . is Associate Professor of French Studies and Medical Humanities at the University of St Gallen. Her area of expertise is death, dying and mourning in twentieth and twenty-first-century literature, philosophy and film. - is Professor of British Cultural and Literary Studies at the University of Vienna and specializes in Medical Humanities, adaptation, transmediality and (neo-)Victorianism.
Published online by Cambridge University Press
Cambridge Critical Concepts focuses on the important ideas animating twentiethand twenty-first-century literary studies. Each concept addressed in the series has had a profound impact on literary studies, as well as on other disciplines, and already has a substantial critical bibliography surrounding it. This series captures the dynamic critical energies transmitted across twentieth- and twenty-first-century literary landscapes: the concepts critics bring to reading, interpretation and criticism. By addressing the origins, development and application of these ideas, the books collate and clarify how these particular concepts have developed, while also featuring fresh insights and establishing new lines of enquiry. Cambridge Critical Concepts shifts the focus from period- or genre-based literary studies of key terms to the history and development of the terms themselves. Broad and detailed contributions cumulatively identify and investigate the various historical and cultural catalysts that made these critical concepts emerge as established twenty-first-century landmarks in the discipline. The level will be suitable for advanced undergraduates, graduates and specialists, as well as for those teaching outside their own research areas, and will have cross-disciplinary relevance for subjects such as history and philosophy. Titles in the Series Law and Literature Edited by University of Western Australia Time and Literature Edited by . University of Ottawa The Global South and Literature Edited by - University of Tu¨bingen Trauma and Literature Edited by . The College at Brockport, State University of New York Food and Literature Edited by . San Francisco State University Animals, Animality, and Literature Edited by , and Florida State University, University of Montreal
Published online by Cambridge University Press
Terrorism and Literature Edited by . San Diego State University Climate and Literature Edited by - University of Surrey Orientalism and Literature Edited by . SOAS, University of London Decadence and Literature Edited by and Goldsmiths, University of London and Hunter College Affect and Literature Edited by University of Cambridge Sound and Literature Edited by King’s College London Magical Realism and Literature Edited by and University of Cambridge and Wheaton College, Illinois Surrealism Edited by University of Melbourne Globalization and Literary Studies Edited by University of Nottingham War and Literary Studies Edited by - and University of Southern Denmark and University of New South Wales Diaspora and Literary Studies Edited by Clemson University, South Carolina Technology and Literature Edited by University of Toronto Literature and Medicine Edited by . and - University of St Gallen and University of Vienna
Published online by Cambridge University Press
Published online by Cambridge University Press
LITERATURE AND MEDICINE ANNA M. ELSNER University of St Gallen
MONIKA PIETRZAK-FRANGER University of Vienna
Published online by Cambridge University Press
Shaftesbury Road, Cambridge , United Kingdom One Liberty Plaza, th Floor, New York, , USA Williamstown Road, Port Melbourne, , Australia –, rd Floor, Plot , Splendor Forum, Jasola District Centre, New Delhi – , India Penang Road, #-/, Visioncrest Commercial, Singapore Cambridge University Press is part of Cambridge University Press & Assessment, a department of the University of Cambridge. We share the University’s mission to contribute to society through the pursuit of education, learning and research at the highest international levels of excellence. www.cambridge.org Information on this title: www.cambridge.org/ : ./ © Cambridge University Press & Assessment This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press & Assessment. First published A catalogue record for this publication is available from the British Library Library of Congress Cataloging-in-Publication Data : Elsner, Anna Magdalena, - editor. | Pietrzak-Franger, Monika, editor. : Literature and medicine / edited by Anna M. Elsner, Monika Pietrzak-Franger. : Cambridge ; New York, NY : Cambridge University Press, . | Series: Cambridge critical concepts | Includes bibliographical references and index. : (print) | (ebook) | (hardback) | (paperback) | (epub) : : Literature and medicine. | Medicine in literature. | Health in literature. : . (print) | .M (ebook) | ./–dc/eng/ LC record available at https://lccn.loc.gov/ LC ebook record available at https://lccn.loc.gov/ ---- Hardback Cambridge University Press & Assessment has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
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We dedicate this book to those who suffer.
Published online by Cambridge University Press
Published online by Cambridge University Press
Contents
List of Figures List of Contributors Acknowledgements
page xii xiii xv
Medico-Literary Pathways, Crossroads, and Side Streets: An Introduction
Anna M. Elsner and Monika Pietrzak-Franger
: Guts, Hollows, and Coils: Inside Stories in Ancient Literature
Chiara Thumiger
Medieval Affect, The Book of Margery Kempe, and Medical Treatments of the Embodied Soul
Holly A. Crocker
Epidemiological Language in Robert Burton’s The Anatomy of Melancholy
Jennifer Radden
Illness and the Novel Aesthetics
Hosanna Krienke
Embodied Traumas in Twentieth- and Twenty-First-Century Literature
Alan Gibbs
: Illness and the ‘Fall’ of Language Steven Wilson ix
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Contents
x
Translating Chronic Pain and the Ethics of Reading in the Personal Essay
Marie Allitt
Physician-Poets and Vitalist Theories of Life
James Morland
Healthcare Anecdotes and the Medically Anecdotal
Brian Hurwitz
Literary Realism and Mental Breakdown
Josie Billington
Time and Narrative in the Age of Postnatural Death: Maylis de Kerangal’s The Heart
Jared Stark
Performance and/as Contagion in the Time of the COVID- Pandemic
Małgorzata Sugiera
The Parallel Chart as Medico-Literary Practice
Daniel Eison
Articulating the Experiential in Graphic Medicine
Kimberly R. Myers
: Malaria Literature: (Post)Colonial Perspectives, Infection, and the Question of Mobility
Jessica Howell and Oishani Sengupta
Forgotten Class: French Literature, Medicine, and Poverty
Loïc Bourdeau
The Human Endeavour: Bioethics and Biocapitalism in Don DeLillo’s Zero K
Justin Omar Johnston
Re-framing and Re-forming Disability and Literature Susannah B. Mintz
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Contents Overcoming Decline (in) Narrative: Episodicity in Stories of Dementia and Ageing
xi
Martina Zimmermann
Literature as a Form of Care? From Therapeutic Narratives to the Literature of Care
Alexandre Gefen
Literature in Collaboration: The Work of Literature in the Critical Medical Humanities
Angela Woods and James Rákóczi
Afterword: Literature and Medicine after COVID-
Anna M. Elsner and Monika Pietrzak-Franger
Index
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Figures
. Athenian red-figure cup attributed to Douris, death of Pentheus (detail) c. BC . Mask of Huwawa, British Museum item ME . Doctor Schnabel von Rom () by Paulus Furst of Nuremberg . ‘This doesn’t look good’ . Desperate to escape . Visceral response . Your brain on comics . ‘Does it hurt here?’ . Checking for other injuries . PTSD . Acknowledgement and plan . Imagining literally
xii
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page
Contributors
is Early Career Teaching and Research Fellow in Twentieth Century Literature at the University of Edinburgh. is Professor of English and Deputy Director of the Centre for Research into Reading at the University of Liverpool. ï is Lecturer in French Studies at the National University of Ireland, Maynooth. . is Professor of English Literature at the University of South Carolina. is Clinical Assistant Professor in the Department of Pediatrics at NYU Grossman School of Medicine. . is Associate Professor of French Studies and Medical Humanities at the University of St Gallen is Research Professor at the French National Centre for Scientific Research, Paris. is Lecturer in English at University College Cork. is Associate Professor in the Department of English at Texas A&M University. is D’Oyly Carte Professor of Medicine and the Arts Emeritus in the Department of English at King’s College London. is Associate Professor in the English Department at Stony Brook University. is Assistant Lecturer in the Department of English at the University of Wyoming.
xiii
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xiv
List of Contributors
is Research Impact Manager at the University of Sussex and Visiting Academic at the Open University. . is Professor of English at Skidmore College. . is Associate Professor of Humanities and English at Penn State College of Medicine. - is Professor of British Cultural and Literary Studies at the University of Vienna. is Professor of Philosophy Emerita at the University of Massachusetts Boston. ˊ is Research Fellow at the Institute for Medical Humanities at Durham University. is Assistant Professor of English at the University of Texas at El Paso. is Professor of Comparative Literature at Eckerd College. is Professor of Literature at the Jagiellonian University of Kraków. is Research Fellow at the Cluster of Excellence Roots, Kiel University. is Senior Lecturer in French and Director of Education in the School of Arts, English and Languages at Queen’s University Belfast. is Professor of Medical Humanities and Director of the Institute for Medical Humanities at Durham University. is Reader in Health Humanities and Health Sciences and UKRI Future Leaders Fellow in the Department of English at King’s College London.
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Acknowledgements
As a joint effort, this volume is an outcome of the editors’ three-year online collaboration. Born in the early stages of the pandemic, it bears traces of our individual and common interests and our contributors’ expertise, as much as testifying to the hardships of pandemic times. The pandemic is indeed present here not only in the volume’s thematic preoccupations but also in the contributors’ extraordinary commitment despite all the additional adversities they have encountered. For this, we thank you from the bottom of our hearts. We are grateful to Cambridge University Press, especially to Ray Ryan and Edgar Mendez, for commissioning the book and for their continuous guidance and advice. We would also like to thank the anonymous reviewers whose suggestions have moulded the final version of this volume. Our thanks also go to Maria Vaccarella, Katja Herges, and David Houston Jones, who have offered invaluable advice and critical comments, as well as to Carina Hilmar, Alina Lange, Tamara Radak, and Ulrike Zillinger for their help with editing and communication. Finally, we are very grateful to Alexander Meienberger for his indispensable help with compiling the index. Last but not least, we thank our respective partners and families for their relentless support and love.
xv
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Medico-Literary Pathways, Crossroads, and Side Streets An Introduction Anna M. Elsner and Monika Pietrzak-Franger Literature and medicine have been intertwined since time immemorial. Language, communication, and healing are some of the most obvious common denominators between the two fields. Throughout history a variety of testimonies to this perennial connection can easily be found: from the poem-like cross-shaped version of the Hippocratic Oath surviving in a twelfth-century Byzantine manuscript to Galen of Pergamum’s treatise on the doctor as a philosopher, from Hildegard of Bingen’s spiritual reflections on holistic medicine to Jean-Martin Charcot’s theatrical demonstrations of female hysterics, just to name a few of the most famous examples. Such and similar texts are records of everyday medical practice; they testify to their authors’ observational skills and interpersonal exchanges, and reflect on the cultural frameworks, available narrative structures, and linguistic means of expression these authors had at their disposal. At the same time, the experiences of health and illness, death and dying, the normal and the pathological have also always – in as much as they are human experiences – been an integral part of literary texts. As such, literary representations of medical practice, healthcare, physicians, nurses, patients, and family members caring for the ill span all historical periods and transcend languages and cultures. They are found in diverse genres, with well-known examples of novels (George Eliot, Marcel Proust, James Joyce, Thomas Mann, Albert Camus), short stories (Anton Chekhov), poems (Gottfried Benn, Emily Dickinson), plays (Shakespeare, Molière, Margaret Edson), essays (Montaigne, Anatole Broyard, Virginia Woolf, Susan Sontag) as well as in (auto)biographical accounts (Margery Kempe, Audre Lorde, Siri Hustvedt, Christoph Schlingensief, Jenny Diski), comics (Marisa Acocella Marchetto, David B., David Small), and, today, on digital platforms. As these examples show, the literature–medicine relationship has always been a dynamic one, with constantly shifting balances between the two fields. In some cases, writing itself is situated at a crossroads of health and medicine, when, for instance, a narrative traces the unfolding of an
https://doi.org/10.1017/9781009300070.001 Published online by Cambridge University Press
. -
epidemic. In other instances, the practice of medicine or the experience of illness turns into a pathway to literature, as is often the case for a doctor or patient writer, or when, for that matter, engagement with medicine merely constitutes a side street on the general literary roadmap concerned with the depiction of human life. Often, such crossroads, pathways, and side streets take turns and/or overlap, thereby testifying to the multiple medicoliterary interconnections that are always shifting and evolving. It is the ambition of this volume to consider the multiple and complex ways in which the two dynamic fields of literature and medicine have been intertwined, how they have crossed over and developed alongside or in the shadow of one another. In contrast to most extant studies or recent companions that have considered literature and medicine as a subfield of the medical humanities, this volume is devoted to scrutinizing literature’s inherent connectedness with medicine. By spotlighting this long relationship, it asks how medicine, as both science and cultural practice, shapes the representation of illness and medicine in literature, along with transforming the literary form. It also considers, albeit to a lesser degree, how literature – the languages of specific diseases, fictional techniques used by physician and patient writers or the medico-literary genre of the ‘case history’ – has put forward specific literary conceptions of medicine and impacted its practice. The collection is unique for three reasons. Firstly, it cuts across a variety of subfields such as narrative medicine, (critical) medical humanities, health humanities, and graphic medicine. By so doing it does not only bring together these varied perspectives in which literature plays different roles, but also allows for new vantage points to arise from their (sometimes conflicting) congregation. Secondly, this volume puts side by side three aspects of the literature–medicine relationship: it juxtaposes historically poignant conjunctions with formal considerations and the politics these participate in. By highlighting the historical, aesthetic, and political aspects of this connection, we plead for a necessary trans- (if not post-) disciplinarity, which may help rejuvenate the work on literature and medicine. Indeed, and thirdly, the volume attempts to offer transcultural perspectives by moving beyond the Anglosphere. Whereas clearly not global, it takes pains to expand the extant emphasis on literature in English to include French, German, Italian, Polish, Russian, and Indian literary imaginaries.
See Thomas R. Cole, Nathan S. Carlin, and Ronald A. Carson, Medical Humanities (Cambridge: Cambridge University Press, ); The Edinburgh Companion to the Critical Medical Humanities, ed. by Anne Whitehead and others (Edinburgh: Edinburgh University Press, ).
https://doi.org/10.1017/9781009300070.001 Published online by Cambridge University Press
Introduction
Against this background, Literature and Medicine aims to provide incentives for further theoretical, thematic, and methodological considerations that go beyond disciplinary, linguistic, and national borders.
Theorizing the Literature–Medicine Connection There’s a paradox here at the heart of medicine, because a doctor, like a writer, must have a voice of his own, something that conveys the timbre, the rhythm, the diction, and the music of his humanity that compensates us for all the speechless machines. When a doctor makes a difficult diagnosis, it is not only his medical knowledge that determines it but a voice in his head. Such a diagnosis depends as much on inspiration as art does. Whether he wants to be or not, the doctor is a storyteller, and he can turn our lives into good or bad stories, regardless of the diagnosis. If my doctor would allow me, I would be glad to help him here, to take him on as my patient.
These are the words used by the writer and literary critic Anatole Broyard at the University of Chicago Medical School in to describe the relationship between literature and medicine. Language and narrative are key to medicine – they are the very means by which to record a healthcare practitioner’s observations and scientific knowledge of the human body. In fact, these means are so important to the clinical encounter that Broyard does nothing less than to reverse the power relationship at its heart. The physician needs words to communicate with a patient, and these words have so much weight that, as Broyard comically suggests, his own doctor would do best to become an apprentice of his patient who happens to be – as a writer – an expert in the use of language. This mutual dependence and how the terms of the collaborative partnership between literature and medicine are negotiated also inform this volume. The flagship journal Literature and Medicine, founded in , cemented the order widely adopted today, namely that literature is positioned before medicine. However, this does not mean that the ‘host discipline’, the one that had actively sought out and/or was cast to influence or court the other, is thus set in stone – rather, it seems, this role has always been a bone of contention and a subject of negotiation. When some of the first courses in the field bearing the name ‘literature and medicine’ were introduced to US medical schools in , the idea
Anatole Broyard, Intoxicated by My Illness and Other Writing on Life and Death, ed. by Alexandra Broyard (New York: Fawcett Columbine, ), p. .
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was to substantiate medical education. Literature and Medicine itself was initially sponsored by the University of Texas Medical Branch and its pioneering ‘Institute for the Medical Humanities’ (which has since been renamed ‘Institute for Bioethics & Health Humanities’). In late , cultural historian George Sebastian Rousseau published a foundational paper in Isis, in which he reviews the state of the field. Tracing the common ground between ‘literature and medicine’ (and impressively exploring historiography as much as the representation of physicians and patients, physician and patient writers, science fiction, autobiography and case histories), he complains about the one-sidedness of the relationship and proclaims that ‘without some reciprocity – from literature to medicine as well as from medicine to literature – there is neither a field nor its state to survey’. To be certain, Rousseau’s critical concern is more the direction of influence (from medicine to literature) than the question of disciplinary grounding, and yet, he also deplores that literary scholarship has largely kept to itself, neglecting ‘the very medico-historical community whose experience and angle of vision it so urgently requires’. When Rita Charon, founder of the narrative medicine programme at Columbia University, wrote about the state of the field in , she presented a different view. Characterizing literature and medicine as a ‘a flourishing subdiscipline of literary studies that examines the many relations between literary acts and texts and medical acts and texts’, Charon mentions the ‘explosive growth in medicine’s interest in literature’. Two important turning points that were formative to the field are the rise of bioethics after the Second World War and the impetus and lasting influence provided by historian and philosopher Michel Foucault. Bioethics, which began to flourish as an academic discipline in the United States in the s, and whose historical origins are rooted in the Nuremberg Code () and the Declaration of Geneva (), was first and foremost conceived as a means of protecting patients’ rights. By restricting the power of medical professionals and imposing on them
Rita Charon and others, ‘Literature and Medicine: Contributions to Clinical Practice’, Annals of Internal Medicine, , (), – (p. ). George Sebastian Rousseau, ‘Literature and Medicine: The State of the Field’, Isis, , (), – (p. ). Rousseau, p. . Rita Charon, ‘Literature and Medicine: Origins and Destinies’, Academic Medicine, , (), – (p. ). Ibid. See Tom L. Beauchamp and James F. Childress, The Principles of Biomedical Ethics (New York: Oxford University Press, ).
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Introduction
the duty to obtain informed consent (Helsinki Declaration ), bioethics fundamentally recalibrated the clinical relationship. A growing emphasis on the legal importance of patient autonomy has also enabled narrative approaches to bioethics, as the uncovering and deciphering of stories is key to ethical judgement. In turn, it was also Michel Foucault’s elaboration of what he called the ‘medical gaze’ in Naissance de la clinique [Birth of the Clinic] (), which prepared a new role for literature as part of the medical experience. Foucault deciphered the power–knowledge dynamics at play in medical practice. The ethical dimension of Foucault’s work on medicine and his documenting of the erasure of what Paul Ramsay later called ‘the patient as person’ led to a rethinking of the power dynamics at the heart of medicine. It thereby also, ultimately, contributed to the opening of the floodgates for patient narratives. It is telling that Michel Foucault himself – thinly disguised as ‘Muzil’ – figures in a seminal literary patient-narrative of the twentieth century, namely, in Hervé Guibert’s A l’ami qui ne m’a pas sauvé la vie [To the friend who did not save my life] (), in which Guibert describes the devasting months of clinical treatment that followed his HIV/AIDS diagnosis. Bioethics and the legacy of Foucault can be seen as having paved the way for the literary multiplication of patient voices published in their aftermath. Even if these two lines of influence were geographically determined (and impacted the development of medical humanities in the United States and Europe respectively and differently), their emphasis on the polyphony of patient voices helped redefine who may be heard and on what terms. As literary critic Anne Hunsaker Hawkins’s work on life writing in the twentieth century highlights, there has been a particular explosion of literary illness narratives since the HIV/AIDS crisis. What Hunsaker Hawkins calls a ‘pathography’ is ‘written by the patient or a loved one [and] can be seen as the logical counterpart to the medical history written
See Stories and Their Limits: Narrative Approaches to Bioethics, ed. by Hilde Lindemann Nelson (New York: Routledge, ). Michel Foucault, Naissance de la clinique (Paris: Presses universitaires de France, ). Paul Ramsey, The Patient as Person: Explorations in Medical Ethics (New Haven: Yale University Press, ). We thank Maria Vaccarella for discussing this point with us. The development of disability studies from the s onwards and the field’s rejection of a medical model of the body further contributed to this polyphony, particularly because, in autobiographical writing, the categories of ‘illness’ and ‘disability’ are often fluid. See Diane Price Herndl, ‘Disease versus Disability: The Medical Humanities and Disability Studies’, PMLA, , (), –. We thank Katja Herges for discussing this with us.
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by the physician or by the medical staff assigned to a particular patient’. The rise of narrative research and Narrative Medicine in the late decades of the twentieth century has led to an emphasis on narrative as a particularly pertinent form both in communicating, making sense, and treating illness. Be it Arthur Frank’s typology of illness narratives, Elaine Scarry’s articulation of pain’s disruptive force or Rita Charon’s method of using literary-analytical categories in medical settings, this privileging of narrative has often been seen as empowering to patients whose voices – thus retrieved – would and could now be heard. At the same time, doctors, as much as nurses – to break down the misconceived idea of the merely binary structure of the clinical encounter – have all but kept silent. The sheer number of contemporary medical writers (Oliver Sacks, Irvine D. Yalom, Siddartha Mukherjee, Paul Kalanithi, Atul Gawande, Danielle Ofri, Henry Marsh, Gavin Francis, Theresa Brown, Christie Watson, Abraham Verghese, Rachel Clarke) testifies to the burgeoning of what has been called ‘the modern medical memoir’. Anton Chekhov, one of the most famous physician writers, used to quip that ‘medicine is my lawful wedded wife and literature my mistress’; while this somewhat delegitimized literature, it also speaks to the doctor’s visceral need for literature. Writing about medicine remains an existential and often politically oriented necessity for some healthcare professionals today; in the climate of austerity measures in medicine, these accounts are also often attempts to make their voices heard within institutional medicine. The examples of medical memoirs cited above speak to the supposed predominance of ‘narratives’, yet the last two decades have also been marked by calls to define the precise meaning of ‘narrative’, to expand the category by focusing on its myriad forms, and, last but not least, to pay attention to non-narrative ways of expressing the experience of illness.
See Anne Hunsaker Hawkins, Reconstructing Illness: Studies in Pathography (West Lafayette: Purdue University Press, ), p. . Margaret McCartney, ‘The Modern Medical Memoir’, The Lancet, , () . Anton Chekov’s Life and Thought: Selected Letters and Commentary, ed. by Simon Karlinsky, trans. by Michael Henry Heim (Evanston: Northwestern University Press, ), p. . See Victoria Bates and Brian Hurwitz, ‘The Roots and Ramifications of Narrative in Modern Medicine’, in The Edinburgh Companion to the Critical Medical Humanities, ed. by Anne Whitehead and others (Edinburgh: Edinburgh University Press, ), pp. –; Angela Woods, ‘The Limits of Narrative: Provocations for the Medical Humanities’, BMJ Medical Humanities, (), –; Sara Wasson, ‘Before Narrative: Episodic Reading and Representations of Chronic Pain’, BMJ Medical Humanities, (), –.
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Introduction
Beyond Discourses of Instrumentalization and Interdisciplinarity The field has changed considerably since George Sebastian Rousseau proclaimed in that the profound interrelation between literature and medicine had not been properly acknowledged in literary criticism. Much, albeit not all, of this dialogue between literature and medicine has been shaped by the previously evoked emergence of the medical humanities. Although the field’s origins can be traced back to William Osler (Regius Professor of Medicine at Oxford, –) and the historian of science George Sarton (who first used the term ‘medical humanities’ in an academic context) – both of whom underlined the importance of humanist thinking for medicine and science – it first developed a specific pedagogy and adjacent research agenda in the s. Today, courses that move between literature and medicine are frequently taught in medical schools as well as literary departments. Some literary texts engaging with medicine, illness, and dying, such as Leo Tolstoy’s The Death of Ivan Ilych, Virginia Woolf’s On Being Ill, or Simone de Beauvoir’s A Very Easy Death, have even become canonical additions to medical curricula globally. Analysing the specific role literature has been assigned in such subfields as narrative medicine, the critical medical humanities, and narrative ethics, this addition to the Cambridge Critical Concepts series seeks to highlight the diversity of theoretical approaches to literature developed under the label of literature and medicine. But the volume also proposes to move beyond the pivotal perspective of ‘use’, which has shaped or at least held a stake in many of these approaches: on the one hand, literary texts in medical schools are frequently used to hone certain skills in doctors, and medicine; on the other hand, by focusing on literature’s engagement with the ‘useful’ domain of medicine, literary courses are used to fend off the crisis of humanities and ensure the survival of literary studies. Yet, as Josie Billington observes, ‘making literature useful can be its own form of forgetting its real uses. It is a difficult balancing act.’ This is an important reminder not to downplay
Rousseau, p. . Brian Hurwitz, ‘Medical Humanities: Origins, Orientations and Contributions’, Revista Anglo Saxonica, , (), –. See Rita Charon, Narrative Medicine: Honouring the Stories of Illness (Oxford: Oxford University Press, ). See Whitehead and others. See Stories Matter: The Role of Narrative in Medical Ethics, ed. by Rita Charon and Martha Montello (New York: Routledge, ). Josie Billington, Is Literature Healthy? (Oxford: Oxford University Press, ), p. .
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the rhetoric of usefulness but to reflect on how different pathways to ‘uses’ – such as institutional politics – have shaped the relationship between literature and medicine and to question these with regard to discussions about the therapeutic capacity of literature that predates the twentieth century. The volume’s multiple methodologies and plural perspectives seek to not only scrutinize discourses of use, but are also guided by what historian of science Mario Biagioli has called ‘postdisciplinary liaisons’ or ‘modular cross-disciplinarity’ that has always existed between literature and medicine. Focusing on the humanities and the sciences rather than literature and medicine, Biagioli responds to C. P. Snow’s diagnosis of the ‘two cultures’. Instead of an inherent suspicion defining their relationship, he proposes that the humanities could think of the sciences as a ‘fellow traveller and likely collaborator’ and vice versa. Based on his view, he charts the future of scholarship as ‘post-disciplinary’, meaning that new formations of scholarship will emerge that translate into ‘time-specific collaborations between the sciences and the humanities around specific problems’. In this volume, the intellectual endeavour to think about literature and medicine together means thinking about certain specific problems or topics – such as chronic pain, cancer, dementia, or disability to name just a few – and to propose that by analysing them outside of a fixed disciplinary framework we get a better understanding of what is at stake. Of course, this view is, to some extent, itself reminiscent of earlier models of thinking science and humanities, recalling not least Robert Burton’s Anatomy of Melancholy. What this also means is that translation and translational approaches are key to the development of the field of literature and medicine. The importance of such approaches has been claimed within medicine and within the medical humanities. On a practical level, most hospitals have translation services for patients unable to speak a country’s given language(s) – these services are effective ways to broaden access to healthcare and ensure effective treatment. Yet little attention has been paid to the
Mario Biagioli, ‘Postdisciplinary Liaisons: Science Studies and the Humanities’, Critical Inquiry, , (), –. Charles Percy Snow, ‘The Rede Lecture, ’, in The Two Cultures: And a Second Look (Cambridge: Cambridge University Press, ), pp. –. Biagioli, p. . Biagioli, p. . See Steven H. Woolf, ‘The Meaning of Translational Research and Why It Matters’, JAMA, , (), –; Douglas Robinson, Translationality: Essays in the Translational-Medical Humanities (New York: Routledge, ); Eivind Engebretsen, Gina Fraas Henrichsen, and John Ødenmark, ‘Towards a Translational Medical Humanities: Introducing Cultural Crossings of Care,’ BMJ Medical Humanities, () .
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Introduction
fact that as a method, translation – even within the hospital – originates in the literary domain and constitutes, first and foremost, a textual process. In other words, translation constitutes the very method by which literature and medicine are connected practically and intellectually. At the same time, we must remember that translation is also a process that produces divergence, difference, and complexity. The volume proposes that these multifaceted reciprocal relationships become even more layered and complex if we take into account local, global, multilingual, and multicultural contexts. By so doing, it fleshes out recent calls for a ‘global and multilingual medical humanities’, one in which the study of linguistic and cultural contexts plays a much more central and defining role. Complexifying denotes widening the scope of languages and cultures, but it also ultimately means questioning and reinventing the canon, which is what Michael Colon has called the ‘unfulfilled task’ and ‘one of [our] generation’s greatest intellectual challenges’. While languages and cultures represented in this volume go beyond the Anglosphere, they still remain largely anchored in the West. By carefully spotlighting the role of class and gender in literature and medicine, along with the connections between human and planetary health, our contributors also signal that the ongoing complication of the literature–medicine connection questions any narrow definition of the field itself. Necessarily selective, the volume seeks to spotlight what has been understudied in the field while at the same time also creating important critical blanks to be filled out in the future.
Roadmap: Structure of the Volume The book’s overall aim is to demonstrate how different pathways to literature and medicine point to a ‘critical entanglement’ of literary and medical cultures. By emphasizing this connection, we draw attention to the way we think about the role of medicine in individual works of literature across genres and centuries along with spotlighting the slipperiness of this
Anna M. Elsner and Steven Wilson, ‘The Languages and Cultures of Pain: Toward a Global Medical Humanities’, Journal of Romance Studies, , (), –. John Michael Colón, ‘On the End of the Canon Wars’, The Point ( October ) [accessed December ]. See, for example, the rise of gender medicine and Elinor Cleghorn’s Unwell Women: Misdiagnosis and Myth in a Man-Made World (London: Dutton, ). William Viney, Felicity Callard, and Angela Woods, ‘Critical Medical Humanities: Embracing Entanglement, Taking Risks’, BMJ Medical Humanities, (), –.
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relationship. With this in mind, the volume has two major goals. First, it proposes to offer the newest – state of the arts – discussions that have been developing on the interface of these ‘two cultures’, thus providing both a solid foundation for more in-depth, nuanced considerations in the future and igniting topical, hitherto little-acknowledged debates. Second, through a balanced combination of thematically broader chapters with more punctual inquiries, it aims to cover a broad spectrum of extant conceptual, thematic, theoretical, and methodological approaches. In order to understand the diversity of literary genres associated with medicine, the varied critical lenses through which the connection between literature and medicine has been studied, as well as the current critical debates, the volume brings together some of the most notable scholars working on the intersection of literature and medicine. By drawing on a range of traditions such as cultural, postcolonial, and gender studies, intersectionality, care ethics, and the aesthetics of literary writing, the proposed volume shows how literary scholarship on medicine has itself shaped and contributed to debates about inter-, trans-, and postdisciplinary thinking within the Humanities at large. Its readers can thus come to appreciate the many ways in which literature and literary criticism have engaged with varied topics of medical importance. They can also gain an overview of the key methodological debates raised by the conceptualization of medicine as a critical concept. In allowing readers to recognize the multiple forms the cross-fertilization of literature and medicine has taken, the book ultimately aims to destabilize not only the relationship between the two fields, but any monolithic understandings of the categories of both literature and medicine. Medicine, just as literature, consists of a variety of subfields, the diversity of which already questions any narrow understandings thereof. In view of this complexity, the volume shows the breadth and depth of the interconnections between literature and medicine, starting with classical discourses on the inner organs of the human body as poetic expedient in ancient literature, before proceeding to consider critical and theoretical responses to literary genres in the Middle Ages, the Renaissance, the eighteenth and nineteenth centuries, and the rich array of twentiethcentury and contemporary perspectives. One of the unique characteristics of the volume is the diversity of genres, forms, and literary critical traditions that we consider. While the proliferation of autobiographical writing on illness at the end of the twentieth century has meant that much scholarship in the field has focused on the category of the illness narrative or (auto)pathography, some contributions in this volume seek to move
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Introduction
beyond narrative. The individual chapters in this volume set out to study different diseases (cancer, infectious diseases, dementia) in specific works; they consider different authorial positions for writing about health and illness (patient writer, physician writers) and situate them within different generic traditions (theatre, poetry, anecdote, literary-philosophical treatise). The collection thereby seeks to travel back and forth between the study of specific texts situated in specific periods and genres, and the theoretical and methodological questions these raise for the field more broadly. In addition, the volume explores these questions at the micro level of language and proposes that the language of health and disease leads to thinking about different cultures of medicine and how they, in turn, have come to shape literary texts. While the majority of works studied in the volume derive from the Anglosphere, the book includes a number of chapters (Alexandre Gefen, Steven Wilson, Jessica Howell and Oishani Segupta, Martina Zimmermann, Loïc Bourdeau, Jared Stark, Małgorzta Sugiera) that focus on non-English as well as non-European literatures. Exposing the importance of specific cultural representations of chronicity, care, contagion, ageing, posthuman health, and the clinical encounter, along with tracing how these have been translated into literature, the book hopes to trigger a discussion on how to take more seriously the reciprocal interactions between particular cultural productions and specific (systems of ) medical care. In order to emphasize the undertheorized and the underhistoricized reciprocity of literature and medicine, we draw attention to the most prominent/influential moments in history where this relationship was particularly under strain, generated unprecedented tensions and distinct conceptualizations of medicine as a critical concept, and led to the evolution of literary and/or medial forms (Part I). The systematic, comparative formal perspective we lay out in Part II allows us to highlight the – often unquestioned and unthematized – influence of medicine on the literary form itself. It enables to ask whether particular medical conditions necessitate a particular form of expression. At the same time, the part demonstrates how a specific literary form, genre, and language can enrich our understanding of illness experiences (acute, chronic, periodic) and how it can question social and ethical assumptions in medical practice. Finally, Part III brings together the most recent debates from within the field in order to expose current tensions and to highlight the effect they have on the conceptualization of the relationship between literature and medicine along with the politics it participates in.
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The first part spotlights selected historical debates that bear on our understanding of medico-literary entanglements. This historical perspective (from Antiquity to the present) allows us to trace both a series of historical shifts and point out some of the conceptual continuities. The individual chapters pursue three concomitant aims. The first goal is to draw attention to particular concepts that developed in parallel in literature and medicine, such as melancholia, contagion, or trauma. The second is to highlight some of the ground-breaking historical, theoretical, and political concerns (e.g. imperialism and medicine, trauma and its articulation) in the context of their evolution and in recent debates. In doing so, and simultaneously referencing various developments in the historical perceptions of medicine, Part I highlights cross-historical common themes such as the frequent intertwining of mental and physical health and the semiotic status and productive encounter of the body and/as text. Taking us back to the origins of the medico-literary connection, Chiara Thumiger focuses on embodiment and the motif of the human and animal body in ancient medical and non-technical literature. Zooming in on the guts, she explores how the abdomen stands for an integral connection between vitality and survival and hence becomes a meeting point between medical and cultural beliefs. The oscillation between the concrete and the symbolic characterizes the guts as a medico-literary motif in ancient literature; it also partakes in Holly A. Crocker’s chapter on The Book of Margery Kempe, which details the foundational place of affect for medical treatments of body and soul in the late Middle Ages. Crocker shows how, in medical manuals of the time, affective therapeutics unites body and soul as well as the secular and the practical, which we have learned to perceive as opposites today. Robert Burton’s Anatomy of Melancholy – which is, among many other things, also a medical manual – proposes that melancholy is an ‘epidemicall’ disease. Jennifer Radden scrutinizes the various meanings of what Burton calls ‘epidemicall’, positing that, while Burton’s observations tell us little about seventeenth-century epidemiology, they find resonance within recent conceptualizations of disease across public health discussions. Another perspective which may prove helpful in thinking about contemporary conception of illness is that provided by Hosanna Krienke and based on her readings of nineteenth-century literature. For nineteenth-century British novelists, illness did not exist just within the individual body, rather, it was conceptualized on the level of communities. Because Victorian texts
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Introduction
expanded their plot structures to highlight precisely this, she argues, their formal characteristics provide a valuable means for critical medical humanities today to consider the social ties involved in the illness experience. What Krienke calls ‘society-wide narration strategies’ – the enmeshing of personal experience with the collective experience of crises – provides the bridge to the final chapter of the part, in which Alan Gibbs examines the rise of trauma theory as a cultural and critical concept. Against a critique of trauma theory’s clinical and cultural prevalence, the chapter considers a range of American trauma texts and their relationship to theories of trauma representation along with drawing attention to their increasing preoccupation with broader sociocultural concerns such as global warming. Gibbs thereby also opens up the field to concerns beyond, yet integral to, human health, pointing towards a merging of planetary, health, and medical concerns in literature. The different conceptualizations of literature and medicine presented in the first part testify to some of the origins of the field, while the following ones explore the ways in which the formal and conceptual issues already mentioned have been developed and reframed. Developments: Forms The second part explores the transformations in the literature–medicine connection by attending to particular literary language, forms, genres, and aesthetics. Here we ask how these aspects of literature might have been conditioned by medicine (e.g. vitalist theories, normative medical ideals about good and bad death, chronic pain). While often muddled under the category of ‘literature’, particular genres, literary forms, and aesthetic traditions offer specific potentialities of expression and articulation: a theatre play can and does do different things than a novel or a graphic narrative. Specific topics and themes have historically also been closely intertwined with particular genres (e.g. the elegy is inextricably connected to loss and mourning). Their literary articulation has often depended not only on a particular cultural context but also on specific literary conventions (e.g. the expression of subjectivity in the novel vs in life-writing). Additionally, while most of the debates on literature and medicine hinge on a traditional understanding of literature as a written narrative, we consider it important to simultaneously open our discussions to a more expansive notion of literature that encompasses graphic novels, along with other multimodal and digital forms. Steven Wilson examines pathographies as forms of writing about illness that allow patients to resist ceding control of their experience to the
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dominance of medical jargon, before analysing the extent to which reading narratives of illness can help patients to understand, and find linguistic forms to articulate what it means to be ill. Focusing on contemporary lifewriting of chronic pain, specifically the form of the lyric essay, Marie Allitt’s chapter suggests that creative literary forms and experimental expression are helping to develop language to meet the experience of pain. Focusing on the poetic form, James Morland’s chapter traces the intersection of poetry and medicine through the figure of the physician-poet in the eighteenth century. It explores how poetry was used to inquire into what medical theories mean for broader philosophical questions about the human body and the self. The following chapter, by Brian Hurwitz, focuses on the anecdotal as a medico-literary form, an unregulated and anti-authoritarian idiom that does not seek to isolate events and experiences from subjective thoughts and feelings about them. While seen with scepticism in the current climate of (evidence-based) medicine, anecdotes can, according to Hurwitz, critically evaluate medical services. In ‘Literary Realism and Mental Breakdown’, Josie Billington reads Tolstoy’s and Ferrante’s texts in relation to the psychoanalytic definitions of psychic pain. As representatives of the pre- and post-Freudian psychoanalysis, these examples of psychological realism anticipate both the concerns and procedures of psychoanalysis and might be regarded as providing an adjunct to modern-day therapeutic practices. Maylis de Kerangal’s novel Réparer les vivants [The Heart], is the focus of the sixth chapter in this part, which explores the bioethical, temporal, and narrative implications of the reinvention of death as brain death. The clash between the medical temporality of death and mythographic literary temporality generates, as Jared Stark demonstrates, a distinct poetic mode, a constitutive form of the age of the postnatural death. In the following chapter, Małgorzata Sugiera juxtaposes the fields of epidemiology and performance in order to disentangle their naturalized relationship during the COVID- pandemic. She demonstrates that the historically distinct epidemiological conceptualization of viruses, which inspired Artaud’s seminal work on theatre as a plague, has little to do with the syndemic imaginary of viral diseases. This historically informed perspective allows the author to reconsider the relationship between performance and contagion. While the previous chapters of this section focus on the way medicine has influenced both literary forms and theories, the remaining two signal the variety of ways in which literature and literary skills have been used in medical education and clinical practice. They thus punctually evoke the plethora of methods adapted from humanities, which find their application
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Introduction
in therapeutic contexts. In ‘The Parallel Chart as Medico-Literary Practice’, Daniel Eison outlines the (dis)advantages of the method developed by narrative medicine pioneer Rita Charon. Next to sketching the method’s many evolutions and its changing application in a number of medical fields, the chapter also traces its usefulness in bolstering clinicians’ critical skills and, importantly, considers some of its practical limitations. If writing a parallel chart is a literary technique that has the potential to subvert traditional balances of power in the clinical setting, Graphic Medicine offers another modality for understanding stories of illness and well-being. While addressing the origins and commitments of Graphic Medicine, Kimberly R. Meyers also shows that comics are particularly effective in the fields of clinical medicine and medical ethics. Her chapter takes the reader through a series of visual thinking strategies that can be employed in this context. Set side by side, these two humanities-derived strategies demonstrate the applied character of literature (and humanities) in medical settings. Applications: Politics The final part of this collection takes up some of the thematic, theoretical, and generic concerns considered in previous chapters, but its emphasis rests on the key debates in literature and medicine in the last couple of decades. The initial four chapters map out current developments. Building on this, the remaining chapters consider theoretical and methodological approaches bound to expand current research questions, corpuses of texts, and their translational applications. Next to the triad of cultural studies (gender, class, race), intersectionality, disability, and posthumanist studies promise to greatly contribute to the reframing of the field. With these perspectives, the question of the anthropocentric primacy also looms large on the theoretical horizon: if health and illness are dependent on a variety of intertwined aggregates (microbes, climactic characteristics, infrastructure, flora, fauna, and cultural practices), how do we have to redraft our understanding of the connectedness of literature and medicine to address that? While this volume cannot offer an answer to this question, it aims at providing solid grounds for these and other future debates. Jessica Howell and Oishani Sengupta open the part by offering a – still underrepresented – postcolonial perspective on the literature–medicine connection. In ‘Malaria Literature: (Post)Colonial Perspectives, Infection and the Question of Mobility’, they examine how Bengali authors of the
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late nineteenth and early twentieth centuries use the mosquito to experiment with scale. In these texts, the mosquito stands for the interconnection of medical, political, and environmental issues. In the combination of medical history and postcolonial readings, the authors offer a much-needed intervention which stresses both the importance of more-than-human entanglements in the conceptualization of illness and the necessity of non-Western perspectives in their considerations. Another intervention is provided by Loïc Bourdeau who demonstrates the growing need for a critical engagement with the concept of class in literary texts that explore medical experiences. Taking the œuvre of French writer Édouard Louis as an example, he scrutinizes the relationship between (white) working class/ poor individuals and medicine, masculinity, and care. By so doing, he spotlights the ‘democracy of care’ that becomes evident in Louis’s texts and which refers to the valuation of horizontal social relations over economic production. Writing about pain, Bourdeau argues, serves Louis to reflect not only on the patient–doctor power dynamics but, more broadly, on France’s healthcare policies and extant structural inequalities. Justin Omar Johnson expands the emphasis on class by considering the historical and structural relationship between bioethics and biocapitalism in ‘The Human Endeavour: Bioethics and Biocapitalism in Don DeLillo’s Zero K’. With a particular focus on the development of consent forms and contract labour, he interprets DeLillo’s treatment of cryonics as a bioethical dilemma too often contained and constrained by historical and ideological conceptions of consent. Through its combination of literary narrative bioethics and feminist relational bioethics, the chapter also offers a form of posthuman literary narrative bioethics as a useful methodology. In ‘Re-framing and Re-forming Disability and Literature’, Susannah B. Mintz likewise provides a new take on the literature–medicine connection by inflecting the perspective on the historically established uses of disability in literature. Inspecting a range of representations of illness and impairment in poetry, narrative fiction, and memoir, she demonstrates the creative possibilities of disability. She thus continues recent scholarship’s exploration of disability’s generative relation to structures of plot and to poetics as well as its epistemological effects, constituting new forms of knowledge. In the next chapter, which focuses on dementia narratives, Martina Zimmermann argues that a reframing of ‘narrative’ as a site that includes episodic self-experience throughout life has the potential to challenge aspects of the decline narrative that nourishes prevalent pessimism about ageing. Gefen’s chapter builds upon the hypothesis that the beginning of
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Introduction
the twenty-first century marked the emergence of a ‘therapeutic’ way of writing and reading. Focusing on twentieth- and twenty-first-century French literary examples, the chapter suggests that diverse literary forms are guided by a politics of attention and the ethics of care. The final chapter proposes to investigate how ‘the literary’ is mobilized in healthfocused research projects whose commitment to interdisciplinarity renders them exemplary of the medical humanities’ critical turn. Drawing on interviews, the methodology of the chapter itself challenges the modes of literary research and shows that literary scholars’ expertise in non-linear and messy narratives often turns into a key anchor point in these projects. It also engages with the politics of ‘the literary’, with some concerns emerging from the interviews, namely that the lack of job security often cuts the long-term involvement of literary researchers short, as much as the fact that literary researchers are often cast in supporting roles, as part of which literature is furthermore often instrumentalized. The chapters in this final part take us from planetary health to care ethics, from exploring narrative challenges arising in ageing societies to the urgent need to allow interconnections of health and class to become visible. They move beyond the ‘use’ of disability and toward its creative potential, all while acknowledging the therapeutic nature of writing as much as the essential role such and other forms of literature and practices of literary scholarship can play in collaborative projects. These theoretical approaches and thematic concerns are further discussed in our Afterword, in which we focus on points that have become particularly relevant in the aftermath of the COVID- pandemic.
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Origins: Histories
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Guts, Hollows, and Coils Inside Stories in Ancient Literature* Chiara Thumiger
The description of the body is perhaps the component we think of most immediately in relation to the field of medicine. This chapter begins here, from the human attempt to map the body, its functions, and illnesses as a place where ancient medical texts and literature meet – indeed, as the common core antecedent to a definition of medicine and medical texts as separate from other literary forms. If medicine is obviously and practically rooted in personal and subjective perceptions of the body, everyday experiences of damage to and wounding of it, and poetic representations of bodily alterations and experience, then analogies between the body and the outside world have been part of our literary tradition (and indeed all literary traditions) from the start. In the history of medicine, the exploration and description of the human body is often designated by the loaded term ‘anatomy’ – a problematic one. Etymologically, ‘anatomy’ evokes dissection (ana-tomeo: to cut into discrete parts, ‘at the joints’); in contemporary medicine and medical education, it identifies the study of the body as an organic arrangement of assembled parts and functional systems; and it is generally used to mean ‘analytical study of or interest in the morphology of the body’ in any cultural context, with the risk of projecting and superimposing contemporary and modern models onto ancient or non-Western cultural systems. I thus use ‘anatomy’ here with a disclaimer, to mean ‘understanding of the morphology and structure of the body’ intended as a sum of parts and systems but also as loose structures, textures, substances, appearances, and conceptual frames. Ancient learned anatomy, intended with this proviso as a competent exploration of the body and its *
I would like to thank the Cluster of Excellence Roots at the CAU University (Kiel) for supporting my research; S. D. Olson for his precious help with the revision of the text; and my colleagues from the collaborative project ‘Comparative Guts’ for stimulating discussions, although they took place when this piece was almost finished. As in Plato’s famous passage at Phaedrus e–a.
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components, and anatomy-based medicine were not born overnight from the dissection of corpses. Instead, they emerged through perpetual dialogue and exchange with surrounding cultural perceptions, to which poetic and philosophical sources bear witness. Poets must from the beginning have expressed this most direct (and surely basic) human awareness, that of embodied existence. Far from simply being the more deterministic ‘template’ of medical inquiries, it is a template which relies on the materiality of the tangible biological object – the body, its substances and tissues, volumes, shape, and parts. These anatomical questions and attempts to answer them offer a set of narratives, symbols, and metaphors as rich as the ‘pathographies’ of modern literature, poetic elaborations on human feelings, and therapeutic or nosological literary compositions. The Greco-Roman case I shall focus on is guts – more cautiously put, the innards, and especially those connected to nutrition and digestion, located below the diaphragm – in poetic representations and the tradition of medicine. I use the term ‘guts’ with caution and intentionally as a collective noun under which different and variously differentiated items of vocabulary, unstable from one to the next, are included. As we will see, the way the body is conceived outside the neat atlases of contemporary medical faculties defies exclusive attribution to one region or the other and relies on connections, analogies, deep or less deep sympathies, and poroi or fluxes connecting and bypassing contiguous bodily regions. This ‘cultural anatomy’ of ancient guts should pay particular attention to the soft nature of this body part. As Aristotle explicitly notes at Parts of Animals (PA) a–, the belly is conspicuously
For the history of ancient anatomical dissection, see Margaret Tallmadge May, Galen, De Usu Partium. Translated from the Greek with an introduction and commentary (Ithaca: Cornell University Press, ), pp. – for the time before Galen; Heinrich Von Staden, Herophilus: The Art of Medicine in Early Alexandria: Edition, Translation and Essays (Cambridge: Cambridge University Press, ), pp. –; Heinrich Von Staden, ‘The Discovery of the Body: Human Dissection and Its Cultural Contexts in Ancient Greece’, The Yale Journal of Biology and Medicine, , (), – on anatomy in Alexandria. On Galen, see Julius Rocca, Galen on the Brain: Anatomical Knowledge and Physiological Speculation in the Second Century AD (Leiden: Brill, ), pp. –; now extensively Claire Bubb, Dissection in Classical Antiquity A Social and Medical History (Cambridge: Cambridge University Press, ). On sympathy, see Brooke Holmes’s various work: ‘Disturbing Connections: Sympathetic Affections, Mental Disorder, and Galen’s Elusive Soul’, in Mental Disorders in Classical Antiquity, ed. by William V. Harris (Leiden: Brill, ), pp. –; ‘Proto-Sympathy in the Hippocratic Corpus’, in Hippocrate et les hippocratismes: médecine, religion, société: Actes du XIVe Colloque International Hippocratique, ed. by Jacques Jouanna and Michel Zink (Paris: Académie des Inscriptions et Belles Lettres, ), pp. –; ‘On Stoic Sympathy: Cosmobiology and the Life of Nature’, in Antiquity Beyond Humanism, ed. by Emanuela Bianchi, Sara Brill, and Brooke Holmes (Oxford: Oxford University Press, ), pp. –. On fluxes and ancient medicine, see the chapters in Bodily Fluids in Antiquity, ed. by Mark Bradley, Victoria Leonard, and Laurence Totelin (London: Routledge, ), especially the one by Coker.
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Inside Stories in Ancient Literature
‘boneless’, unlike the chest in which the heart is protected by the ribs: ‘The purpose of this is that the swelling which necessarily takes place after the receipt of nourishment may not be hampered, and (in females) to prevent any interference with the growth of the foetus.’ This softness, evidently linked to vitality (nourishment, reproduction) and vulnerability, translates into a particular mystery and intricacy. If the body as externally appraised object enjoys a degree of visible objectivity, its inside remains even today conspicuously ‘imaging-dependent’, its details only discernible through a variety of techniques (in contemporary science) or through evisceration (in the ancient world). Both imaging and evisceration belie in different ways any claim on the body as a phenomenological unity: its parts are seen only when the body no longer exists. In short, the innards only exist ex corpore, even sine corpore, a fact that should warn us against the reality or objectivity of any talk of ‘my liver’ or ‘my stomach’ as referring to anything other than received notions or holistic feelings expressed in metaphor. Experientially, the innards remain elusive. Heuristically, they appear remarkably separate from their owner, unlike a hand, a leg, or the head, for example, which can metonymically represent or symbolically evoke an individual human identity in statues, reliefs, or poetic language. As such, they enjoy the combination of intimate closeness to the human person with the uttermost uncanny extraneity which works as a perfect material for metaphor. On this premise, it is only through an exploration of literary and medical sources in dialogue that the ancient understanding of the interior of the human body can be reconstructed.
The Poetic Belly: Vulnerability, Nutrition, Life This survey starts with a chronological and genre-based simplification in mind: in the beginning was poetry, and we should turn to Homer as the earliest, and remarkably (if selectively) rich source regarding the human body. The Iliad, as a poem of war, is especially abundant in descriptions of the body and its psychosomatic ‘inside’ as it spills out to the surface when pierced by wounds. In epic, battle wounds and maiming are a fundamental part of the action, but display specific characteristics.
Recall Celsus’s remarks that the animated body, once opened, ceases to live or to be what the researcher was after in the first place (necesse est tale, quale mortui sit, non quale vivi fuit, Med. Proem. = , – Marx). Glenn Most, ‘Disiecti membra poetae: The Rhetoric of Dismemberment in Neronian Poetry’, in Innovations of Antiquity, ed. by Ralph Hexter and Daniel L. Selden (New York: Routledge, ), pp. –; Christine Salazar, The Treatment of War Wounds in Graeco-Roman Antiquity (Leiden: Brill, ). Cf. Most, p. ; Robin Lane Fox, The Invention of Medicine: From Homer to Hippocrates (New York: Basic Books, ), pp. –.
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Just as for psychological life, the vocabulary used in both Homeric poems to describe the inside of the body testifies to a mapping of regions and subdivisions in part different and certainly more varied than those later found in medicine. Stomachos, the term most familiar to us, refers to the throat, rather than to gastric entities (stoma, the standard Greek word for ‘mouth’, can also refer to the mouth or ostomy of the stomach in later medicine). In addition, several words are used to qualify the innards of the lower abdomen, the area ‘around the belly-button’ often targeted by weapons. These are gastēr (‘hollow, pouch’); ta entera (‘the things inside’); keneōn, nēdys, ta spanchna, and cholas, all evoking a container shape, with koilia (literally ‘cavity’, as well as ‘sinuosity’) the standard term in later medicine and literature, but absent from the Homeric poems; and kardiē, later ‘heart’ or ‘chest’ but also used in classical medicine to refer to abdominal parts. Adverbially, as noted, par’omphalon is also common to indicate the area ‘around the lower belly’ generally. In all these, the quality of shallowness, ‘pouchiness’, appears to dominate. nedys indicates the belly, bowels, or even womb. keneōn/kenos is used for the belly, but also for the hollow between the ribs and the hip, the flank, and more generally for any hollow or vacant space in the body. cholas/cholades is perhaps more precisely employed for the contained item – ‘bowels’, ‘guts’ – but is still employed for the cavity as well. gastēr is more precisely identifiable with the fleshy stomach (although the meaning ‘container’ is also possible); entera and splanchna more clearly refer to the solid innards in the belly. A fragment from the Alexandrian physician Herophilus illustrates this combination of container/contained (b Von Staden, –), as he describes the liver as ‘concave and uneven (ensimon kai anōmalon)’ where it touches ‘against the abdominal cavity (ensimon kai koiliai) and against its lump (kai tōi kurtōi tēs koilias)’: koilia signifies this place that combines cavernous space and contained protuberance. Two directives thus emerge: the empty cavity and its filling, and a dynamic representation that, in Homer at least, appears motivated by the actions of piercing, causing to flow, or attempting to retain inside. This passivity and activity, and corresponding vulnerability, are to be understood in the most literal terms: the parts emerge to consciousness and produce knowledge specifically through trauma and violence (be it
For instance at Epid. , iv (– Jouanna = . L.), where the kardia is involved with postpartum problems: ‘at first she suffered in the kardiēn and the right hypochondrium. Pains in the genital organs’ (edition used: Jacques Jouanna, Epidémies I et III (Paris: Les Belles Lettres, ). Jones’s Loeb translation ‘stomach’ is perhaps too precise, but ‘heart’ would surely be wrong; see Epidémies I et III, p. , which identifies kardia with ‘mouth of the stomach’.
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Inside Stories in Ancient Literature
inflicted on oneself or observed in others). Some examples: at Iliad (Il.) , –: ‘the stone’s thrower ran up beside him, Peiros, and stabbed with his spear next to the navel, and all his guts poured out on the ground, and a mist of darkness closed over both eyes’. The terms used are par’ omphalon, ‘round/next to the navel’, and cholades, which are said to ‘spill around’ before death. At Il. , κενεών is used: ‘would that I had smitten you in the nethermost belly (neiaton es keneōna), and taken out your life!’: the part is the receptacle of thymos, whether metaphorically or literally. The shape is perceptibly that of a hollow container – concretely, a tripod is referred to with similar language in cooking or other domestic scenes, as at Il. , : ‘they set the belly of the cauldron (gastrēn . . . tripodos) upon the blazing fire for filling the bath, and poured in water’. In violent scenes, the content of this space is focused on. At Il. , , Polydorus dies ‘clasping his bowels (entera) in his hand and sinking to earth’, while at Il. , –: ‘. . . Aias in his turn smote wise-hearted Phorcys, son of Phaenops, full upon the belly (kata gastera) as he bestrode Hippothous, and he broke the plate of his corselet, and the bronze let forth the bowels (entera . . . ēphys’) through it.’ The body part, wounds to which are mortal, is critical. At Il. . –, ‘Him did lord Agamemnon smite with his spear upon the shield, and this stayed not the spear, but clean through it passed the bronze, and into the lower belly (neirairēi . . . en gastri) he drove it through the belt’; as often, the belly is the fatal point of penetration. So too at Il. , or , , where the same formula appears. In these examples, as generally in the poem, guts are important to express vulnerability and vitality, and they are particularly holistic in this respect: it is ‘through’ them that an individual is pulled down and killed, his life drawn out, and so on. Nutrition is the other side of the coin in conveying this vitality: food, satiety, and fullness in animal similes can be understood as reverse image of the killing ‘through the abdomen’. In Homer, of course, there is no interest in the physiology of digestion, but rather an account of the mechanical process. Consider Il. , –: ‘they rushed forth like ravening wolves in whose hearts (stēthesin) is fury (thymos) unspeakable – wolves that have slain in the hills a great horned stag . . . the heart in their breasts unflinching, and their bellies gorged full (peristenetai de te gastēr)’. The stomach is full, distended with the devoured meal, an image of satiated fury, satisfaction and success. At Odyssey , –, a classic lion simile qualifies the hero: ‘Forth he came like a mountain-nurtured lion trusting in his might, who goes forth, beaten with
Trans. Lattimore.
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rain and wind, but his two eyes are ablaze . . . his belly (gastēr) bids him go even into the close-built fold, to make an attack upon the flocks.’ The gastēr spells courage, drive, and force, as well as the urge to procure food. The belly is also a source of ethical challenge in its blind yearning for satisfaction, as in an admission of reckless temerity at Od. , –: ‘my belly, that worker of evil (gastēr . . . kakoergos), urges me on, that I may be overcome by his blows’. And again, at Od. , : ‘for their cursed belly’s sake (henek’ oulomenēs gastros) men endure evil woes, when wandering and sorrow and pain come upon them’. After all, the evil to humanity that is woman was described by Hesiod at Theogony precisely in terms of a greedy stomach: like drones, women ‘stay at home in the covered hives and reap the toil of others into their own belly (es gaster’)’. To this greedy vitality belongs also the function of gastēr as womb and receptacle of new life, implied at Il. , , where homogastrios, ‘product of the same womb’, means ‘brother’. This brief sampling of Homeric terminology reveals how, in the oldest Greek literary texts, the cavity of the lower torso and its content are present as a matter of volume, first of all, in both the content and the contained sense and vitality, not of functional distinction. The ‘guts’ emerge as a ‘gastric continuum’ whose vocabulary is partly interchangeable and lacks a clear distinction of parts. More poetic examples and literary narratives illustrate this image of the body in non-discrete terms, even if they revel in its penetration and material destruction. The famous and most detailed surviving literary dismemberment from the classical period, the sparagmos of Pentheus in Euripides’ Bacchae (end of the fifth century), displays no anatomical interest beyond the use of conventional terms (‘chest’ is indicated vaguely and redundantly through the terms thymos, kardia, and phrenes), and leaves the inside of the belly not just remarkably untouched but unnamed. The suicide through mutilation of the deranged Cleomenes in Herodotus . (fifth century), despite its notable goriness, presents the innards as undistinguished pulp. The Spartan is said to have grabbed a knife and ‘set about slashing himself from his shins upwards. From the shin to the thigh he cut his flesh lengthways, then from the thigh to the hip and the sides, until he reached the belly (es tēn gastera), and cut it into strips (katachordeuōn). Thus he died . . . .’ chordeō and katachordeuō are usually employed for sausages (chordē is ‘gut’, ‘tripe’ as viand, or ‘string of gut’): a strip-like, elongated form seems to be imagined, on analogy with
See Chiara Thumiger, ‘Bodies with Organs, Bodies without Organs’, in Body Technologies in the Graeco-Roman World: Techno Bodies, Sex and Gender, ed. by Giulia Chesi and Maria Gerolemou (Liverpool: Liverpool University Press, ).
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Inside Stories in Ancient Literature
Figure . Athenian red-figure cup attributed to Douris, death of Pentheus (detail) c. BC. Kimbell Art Museum, Fort Worth, Texas/Art Resource, NY/Scala, Florence
animal guts and cured preparations. The idea of such a self-performed mutilation is entirely fantastic. But it communicates something about the view of the inside and its detached conceptualization as manipulable and organized in strips. Figure ., Pentheus’s severed torso, offers a possible comparison contributing to an understanding of this early view. The conspicuousness of the belly in these archaic and classical sources is thus not primarily in its location but in its volumetry, and not in its functionality but in a vitality that is intrinsic and self-explanatory.
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Functionality will be discovered later and ‘written over’ the already present schemata. The qualifiers of guts which constitute the background of medical and biological inquiry are accordingly hollowness, fullness vs emptiness, ‘pierceability’ and ‘spillability’. Physiologically, they are nutrition, fullness, life, and procreation; existentially, life, survival, and drives thereto; psychologically, force, desire, temptation, and fierceness; and morally, greed, temptation, obstinance, and obtuse force. Some of these connections might appear obvious. Hunger, death by wounding, and food processing are – perhaps naturally – often experienced as localized in the lower torso in (human) animals. But the point is to illustrate how these idioms, subjective representations, and semantic clusters frame and shape the subsequent medical-scientific imagination in their tradition and drive it in directions that are not inevitable, paving the way or rather providing the edifice and context for the biological and medical discussions of classical medicine and Aristotelian biology.
The Natural-Philosophical Account of Guts: Shapes and Parts, Nutrition, Digestion Medicine and natural philosophy are interlaced with one another in complex ways at the very beginning and throughout, making it impossible to separate their sources neatly. Both are also deeply informed by wider and especially poetic vocabulary. Although systematic inquiry into animal bodies begins in our tradition with Aristotle and his investigations preserved by Parts of Animals and Historia Animalium, earlier texts at the crossroads of medicine and natural philosophy are illuminating for their information regarding body parts (significantly, in the context of cosmogony and cosmology more than clinical medicine). In a text from the Corpus Hippocraticum, De Carnibus (On Fleshes, second half of the fifth century), the belly is mentioned alongside other items in a discussion of the creation of bodies, and the terms used to designate this part – or, significantly, this group of parts – emphasizes precisely hollowness and containing capacities, along with an additional element, an affinity to a marshy primordial soup. At Fleshes – (– Potter = VIII.–
See Philip van der Eijk, ‘On “Hippocratic” and “Non-Hippocratic” Medical Writings’, in Ancient Concepts of the Hippocratic, ed. by Lesley Dean-Jones and Ralph Rosen (Leiden: Brill, ), pp. – and the discussions in Aristotle Reads Hippocrates, ed. by Hynek Bartoš (Leiden: Brill, forthcoming), especially Perilli’s chapter. For the dating of the texts in the Hippocratic Corpus, I follow Elizabeth Craik, The ‘Hippocratic Corpus’: Content and Context (London and New York: Routledge, ).
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Inside Stories in Ancient Literature
L.) bodily organs, parts, and ‘tissues’ emerge into existence after a cosmological heating of the earth: ‘as with time the earth was dried out by this heat, the materials left behind engendered putrefactions (sēpedonas) about themselves, which had the form of tunics (chithonas)’ (, VIII. L.). From these ‘tunics’, different components of the body, different kinds of flesh, sarka, are produced by different kinds of lumping together of the cold and hot matter, of the fat and the lean, and shaped into voluminous forms now hollow, now full (vessels, membranous or tunic-shaped organs, such as the intestines, vs bones and solid organs), denser and harder vs softer and thinner, and so forth. Here is the text, Carn. ( Potter = VIII. L.): In this way the pharynx, oesophagus, stomach and intestines as far down as the rectum were made/became hollow (κατὰ δὲ τὸν αὐτὸν λόγον καὶ ὁ φάρυγξ καὶ ὁ στόμαχος καὶ ἡ γαστὴρ καὶ τὰ ἔντερα ἐς τὸν ἀρχὸν κοῖλα ἐγένοντο): for as the cold in each case was heated, the part around the outside, being gluey, was baked through and became a tunic, the membrane around it, while the cold in the inside, not containing much that was fatty or gluey, melted completely and became liquid. . . . In the case of the other hollow parts, it happened in the same way: where there was more gluey material than fatty, a tunic, membrane, was formed, while where there was more fatty than gluey, bones were formed.
Hollowness belongs profoundly to the nature of certain body parts and is connatural to their ‘histology’ and genetics. By virtue of this, these formations are grouped together in the category splanchna (at Carn. , Potter = VIII. L.) and are again, due to their hollowness, seen as homologous to vessels: ‘the internal parts arise, in my opinion, as follows – about the vessels I have spoken of above’. The hollow, ‘tunic-like’ nature of the innards is fundamental and allows them to suck, contain, and absorb. This assessment, to be sure, concerns the lungs and liver as much as the intestines and stomach (in our own cautious identification), all perceived as analogous to ‘vessels’. The interchangeability of the parts should
Not so much on their uncanniness, it seems to me, which is a function of a modern gaze: see Brooke Holmes, The Symptom and the Subject (Princeton: Princeton University Press, ), p. n. ; p. on koilia as ‘mysterious cavity’ defined by its uncanniness and darkness. In fact, the innards are distinguished, if not identified; they are discussed and identified as empty, sack-like volumes. This appears to be the building unit of the interior of the body, to which vessels are also assimilated. In this sense, koiliē as the whole inside of the body as so conceptualized, with Holmes, risks being misleading, since the body as a whole is never such a hollow, and the koiliai are known and evoked terminologically, their tunic-like quality and convolutedness being as important as their potentially awe-arousing concavity.
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be noted: they are all entera or splanchna, and where gastēr or stomachos are mentioned, they are semantically or complementarily interchangeable. This attitude leaves traces in notable anatomists typically considered ‘medical’ or ‘biological’. Aristotle, in his natural-historical survey in PA . (b–), also clusters these parts together as koilian . . . kai pasan hypodochen tēs trophēs kai tou perittōmatos, ‘stomach [?] and every kind of receptacle for food and for residue’. Aristotelian biology is our first extensive source in which organs (including those of the belly) are separated and physically described as extruded or extrudable, but an intermittent lack of neat distinction and focus on volumetry can be seen here as well. In PA , at b–, various innards (excluding blood vessels and the heart) are introduced as splanchna, and Aristotle moves on to analyse lung, liver, spleen, bladder, kidneys, diaphragm, and membranes in general (b–b). At PA the guts in ‘our’ sense are discussed (a–a), and Aristotle mentions two parts, the koilia as placed at the end of the oesophagus (which would make it our stomach) and the enteron (thus our intestine, one would think). Both are qualified as places, parts (topon, morion, a, ) apt to receive the food and its leftovers (perittōma). As functionality gains importance, an additional feature is embedded into the description of guts, that of coils and complexity. The background is that an animal’s teeth and its voracity are associated with variations in its stomach: animals with less efficient teeth have larger bellies (‘nature makes up for the deficiency of the mouth by means not only of the heat of the stomach (koilia) but also by its special character’, b–). In fact – and here we come to the point – animals ‘which have a straight intestine (euthuentera) are especially gluttonous, since the food passes through quickly’ (a–). The morphology of intestinal coils is a key point of variation and quality. At a–, the intestine (hē physis . . . tōn enterōn) has its natural place immediately after the stomach (meta tēn koilian) in all animals. Like the stomach (hē koilia), this part too has many forms. In some animals, it is simple and similar throughout its length, when uncoiled. In others it is not similar throughout, but is wider near the stomach, and narrower towards the end (which is why dogs have difficulty discharging their excrement). In the majority, however, it is narrower at the top and wider at the end.
The very brief treatise On Anatomy (., Craik = .–) included in the Corpus Hippocratic and from an uncertain date between the fifth and fourth centuries, has only a short passage on our topic: ‘the belly (κοιλίη), lying beside the liver, on the left side, is all sinewy. From the belly comes the intestine, which is similar [to other creatures].’
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Inside Stories in Ancient Literature
In the long passage, the coiled, less coiled, simple, and homogeneous (or the contrary) are debated, which testifies to the important, non-fortuitous character of this ‘coiledness’ (a–b). Here too, however, entera is not the only term used. At b and , and below, ē anō koilia and ē katō koilia are employed for the upper/lower gut with the same meaning, ‘intestines’, while the quality of being less coiled is referred to as being ouk eythyentera (b). nēstis is the only technical term which appear to be used with some stability, here literally ‘fasting’, empty – meaning the jejunum, or small intestine. In conclusion, Aristotle’s account of the guts appears to be based on close cross-species observation and analysis, but still orders the material along qualitative lines: these parts are receptacles, characterized by their vacuity and coils. He also inherits a flexible, often synonymic vocabulary which gestures towards a continuum among the innards more than a stable separation between them.
Cosmic and Cosmogonic Extensions: Body, Earth, Universe This ambivalence is also present in cosmic and cosmogonic extensions. In poetic and natural-philosophical sources, the perceived hollowness and depth of the guts are converted into a cosmological image, that of the earth as repository of wealth and nutriment, able to produce fruit and offspring, and as such exposed to pillaging and exploitation. On the negative side, through its link with dirt, matter, and after-death decay, the same earth, like the guts in the human body, is symbolic of impurity, obfuscation, and ontological subsidiarity. To understand this ambivalence in the representation of ‘guts’ and the homology with the earth and the ‘underworld’ it contains, we should briefly return to the view of the human body as shaped by a ‘vertical’, hierarchical ranking. Both Plato and Aristotle clearly organize the body
On these connections with particular reference to tragedy, but relevant to the discussion here, see Ruth Padel, In and Out of the Mind: Greek Images of the Tragic Self (Princeton: Princeton University Press, ), ch. ; Emmanuela Bakola, ‘Interiority, the “Deep Earth”, and the Spatial Symbolism of Darius’ Apparition in the Persians of Aeschylus’, Cambridge Classical Journal, (), – (pp. –); ‘Seeing the Invisible: Interior Spaces and Uncanny Erinyes in Aeschylus’ Oresteia’, in Gaze, Vision and Visuality in Ancient Greek Literature, ed. by Alexandros Kampakoglou and Anna Novokhatko (Berlin and Boston: Walter de Gruyter, ), pp. – also explores earth imagery; the body parallel, however, remains at the margins in both studies. See Yulia Ustinova, Caves and the Ancient Greek Mind: Descending Underground in the Search for Ultimate Truth (Oxford and New York: Oxford University Press, ) regarding caves and cave experiences in ancient Greece, and on a positive meaning of caves in general. At , she mentions the Phaedo passage I discuss below, but with no parallel to the human body and its necessary but imperfect ‘guts’.
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along an up/down axis, whose ideal poles are the caput, the head (and heart, in this respect functionally equivalent), on the one hand, and the guts, on the other. This famous grading can be found in Plato’s Timaeus (d–a) and in Aristotle, On the Parts of Animals ., b. This division in the body mirrors a wider, more general division in the universe: In man more than in any other animal, the upper is man’s unique (and ‘natural’) posture. And the lower parts of the body are determined in accord with what is naturally upper and lower: in other words, upper and lower in man correspond with upper and lower in the universe itself (μάλιστα δ᾿ ἔχει διωρισμένα πρὸς τοὺς κατὰ φύσιν τόπους τὰ ἄνω καὶ κάτω ἄνθρωπος τῶν ἄλλων ζῴων· τά τε γὰρ ἄνω καὶ κάτω πρὸς τὰ τοῦ παντὸς ἄνω καὶ κάτω τέτακται, HA a–).
This natural-philosophical and cosmological point is interwoven with imagery and personifications. The belly (gastēr) is an all-consuming wild beast, a thremma in the words of Plato, for which the koilia provide a manger through a process of ‘domestication’ (cf. in the same spirit the manger, phatnē, at Arist. PA ., a). This part of the body is thus also a treasure chest, which works as a storehouse for the body and a cauldron concocting and supplying nutriment. As such, it enjoys an affinity to a different kind of soup, the primordial, muddy one from which life originated. Aristotle explains that all bodily innards (with the exception of the heart) are made of blood residue: ‘they may be compared to the mud (ilys) which a running stream deposits; they are, as it were, deposits (procheumata) left by the current of blood in the blood vessels’ (PA ., b–). At work here is an earthy view of the formation of the body as an event happening in a landscape, similar to the one encountered in the Hippocratic Fleshes already mentioned, where individual parts similar to organs, ‘tunics’, arise from putrefying moisture and mud. This scenario can be further appreciated in dialogue with poetic examples: Prometheus forms the human body from clay in fluvial (or pluvial?) waters at Ovid Met. ., ‘first mingling it with water of new streams’, mixtam fluvialibus undis (mss. pluvialis), while Hyginus preserves a myth of the creation of man by Cura using the clay of a ‘certain river’, quendam fluvium, to mould it. The birth of humanity from the earth deposited by a stream influences all these and posits the muddy guts of the earth, where life is engendered, as a clear parallel to the human guts in the body.
See also PA ., a–; and Aristotle’s fondness for the metaphor ouranos, ‘sky-vault’, for the palate, seat of the most noble activity of speech (e.g. PA a). Compare also PA ,, b–.
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In the famous and much discussed section in Plato’s Phaedo where Socrates describes the world, hē gē, and the parts of it humans inhabit, these earthy, gutty narratives about the origin of animal bodies are endowed with further evaluative implications. Our kind is relegated to ‘muddy caves’ beneath the surface of the ‘real’ world, whose beauty and superiority humans mostly remain unaware of and excluded from (b–c). The world we know and can perceive is constituted of ‘many hollows’ of varied forms and sizes (πολλὰ κοῖλα καὶ παντοδαπὰ, b) and is located on an impure and polluted level of being, ‘into which the water and mist and air have run together’, while ‘the earth itself is pure and is situated in the pure heaven in which the stars are . . . the water, mist, and air are the sediment of this and flow together into the hollows of the earth’ (eis ta koila tēs gēs) (b–c). In several details these κοῖλα, ‘cavernous spaces’, connected as they are by a reticulum of channels and drenched in fluid, evoke the koiliai of the body, those cavities of the belly where the lower drives reside. In these impure receptacles, koila/enkoila (c), we live unaware, as in a cosmological ‘belly’, enslaved to the impressions and hallucinations that characterize the appetitive soul, as declared in the Timaeus (d–d).
See Dorothea Frede, Platons ‘Phaidon’ (Darmstadt: Wissenschaftliche Buchgesellschaft, ), pp. –; Elizabeth Pender, ‘The Rivers of Tartarus: Plato’s Geography of Dying and Coming-Back-to Life’, in Plato and Myth, ed. by Catherine Collobert, Pierre Destrée, and Francisco J. Gonzales (Leiden: Brill, ), pp. –, reading the Tartarus region as a ‘superbody’; Irmgard Männlein-Robert, ‘Von der Höhle in den Himmel: der Jenseitsmythos des Phaidon oder Sokrates im Glu¨ck’, in Plato’s Phaedo: Selected Papers from the Eleventh Symposium Platonicum, ed. by Gabriele Cornelli, Thomas M. Robinson, and Francsco Bravo (Baden-Baden: Academia Verlag, ), pp. –; Plato: Phaedo, ed. by Christopher Rowe (Cambridge: Cambridge University Press, ), pp. –; David A. White, Myth and Metaphysics in Plato’s Phaedo (Selinsgrove: Susquehanna University Press, ), pp. –, at p. recognizing the analogy between ‘the hollows, channels, and rivers’ and ‘the circulatory and respiratory systems of a human body’; Paul Friedländer, Platon (Berlin: De Gruyter, ), pp. –; Plato’s Phaedo, ed. by James Burnet (Oxford: Oxford University Press, ), pp. –, ad loc. ‘systole and diastole of the heart’; Clinton DeBevoise Corcoran, Topography and Deep Structure in Plato: The Construction of Place in the Dialogues (Albany: SUNY Press, ), pp. –. On medicine in the Phaedo in general, more as tradition and background to philosophical inquiry see David Ebrey, Forms, Death, and the Philosophical Life (Cambridge: Cambridge University Press, ), pp. –, –. to koilon is also used for body parts alongside koilia. Compare also [Aeschylus] Prometheus Bound, a tragedy often singled out as sophistic and philosophic in inspiration, –, where early humans are described as cave-dwelling ants whose senses are dull and whose understanding is limited: though they had eyes to see, they saw to no avail; they had ears, but they did not understand; but, just as shapes in dreams, throughout their length of days, without purpose they wrought all things in confusion. They had neither knowledge of houses built of bricks and turned to face the sun, nor yet of work in wood, but dwelt beneath the ground like swarming ants, in sunless caves.
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The analogy between the belly and the convolutions of its innards, on the one hand, and a form of underworld – whether inferior, infernal in a metaphysical sense, or merely geologically subterraneous – is also confirmed by the long, complex history of the labyrinth as visual pattern and organization of space and movement, in its classical version but even more conspicuously in older Babylonian versions. The interpretation of the evidence is still controversial in several details. For our purposes, however, as Myers Shelton shows, it seems beyond doubt that labyrinthine patterns express the entrails of the body and the intestines in particular as object of extispicy (the examination of viscera to read the will of the gods). As such, they have an association both with divine communication and with the underworld. ekal tīrāni, or ‘palace of the coils of the colon’, is an Akkadian expression indicating the sheep’s intestines which were studied for divinatory purposes, casting the body as a containing architecture and the guts as a critical interface with the gods. The daemon figure Humbaba, represented in several artefacts as a staring mask whose face is covered in intestines (Figure .), is perhaps the most striking stylization. To return to our Greek material, the muddy and physically, ontologically and epistemologically inferior underworld, perforated by holes infested with life, is also an active, fructiferous core where the life–death exchange take place, in which creatures come into being and to which their matter is bound to return when life expires. According to Alexander of Aphrodisias, Anaximander Db (Laks–Most –) already spoke of the ‘hollows of the earth’ in whose moisture the sea formed. According to Porphyry, Pherecydes of Syros ‘spoke of nooks, and hollows, caves and doors and
I am very grateful to Maddalena Rumor for her help and insights on this material. Richard Myers Shelton, ‘The Babylonian Labyrinths’, Caerdroia, (), –. Károly Kerenyi’s suggestion (‘Studi sul Labirinto. Il labirinto come disegno-riflesso di un’idea mitologica’, in Nel Labirinto (Turin: Bollati Boringhieri, /), pp. –, originally published as ‘Labyrinth studien: Labyrinthos als Linienreflex einer mythologischen Idee’, Albae Vigiliae, (), –), following Franz Marius Theodor Böhl, ‘Zum Babylonischen Ursprung des Labyrinthos’, in Miscellanea Orientalia dedicata Antonio Deimel annos complenti (Rome: Pontificio Istituto Biblico, ), pp. –; Myers Shelton, pp. –, disagrees. I cannot judge the Babylonian evidence, but the Vergilian representation of Aeneas’s descent into the underworld at Cumae (esp. Aen. VI, –) places the labyrinth (visual and figurative) and Minoan narratives conspicuously at the centre – cf. William Fitzgerald, ‘Aeneas, Daedalus, and the Labyrinth’, Arethusa, (), –; Emily Gowers, ‘Virgil’s Sibyl and the “Many Mouths” Cliché (Aen. .-)’, The Classical Quarterly, (), –, esp. pp. – n. with further bibliography. On Humbaba’s face, see Sidney Smith, ‘Assyriological Notes’, The Journal of the Royal Asiatic Society of Great Britain and Ireland, (), –, pp. –; Myers Shelton, p. (more sceptical about the underworld connection). Early Greek Philosophy, ed. and trans. Andre Laks and Glenn W. Most (Cambridge, MA and London: Harvard University Press, Loeb Classical Library, ), pp. –.
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Figure . Mask of Huwawa, British Museum item ME
gates (μυχοὺς καὶ βόθρους, ἄντρα καὶ θύρας καὶ πύλας), and meant by these terms allegorically the births and departures of the souls’ (R, Laks– Most ). Biologically, in HA a– Aristotle speaks explicitly of kind of fructiferous pockets in the muddy waters of rivers called ‘innards of the earth’, entera gēs, where creatures are born ‘spontaneously’ from mud and humidity (γῆς ἐντέρων, ἃ αὐτόματα συνίσταται ἐν τῷ πηλῷ καὶ ἐν τῇ γῇ τῇ ἐνίκμῳ); this happens ‘in the sea and rivers, when there is a good deal of putrefying matter . . . where the heat of the sun is strong’. It is thus hardly surprising that the only place in the body (other than the female womb) where new beings can come into life is precisely the intestines, entera, as the late-antique medical doxographer Aetius notes in his discussion of ‘flat worms’ (IX, Calà): ‘The flat worm, as someone would say, is a transformation of the lining membrane inside the small intestine into an animal-like body (epi ti sōma zoōdes) . . . the animal created (poiēthen) within the entera, as soon as it has consumed the fresh food, later begins to erode the solid parts of the body.’ The homology between the interior of the body and that of the earth is not only an extension from body to world of the kind familiar for example from cognitive theories of metaphor, illustrating perhaps more banally how all human language and abstract thought must originate in concrete
The phrase ‘innards of the earth’, entera gēs, will be later simply used for earthworms – cf. Aetius, Libri Medicinales IX (). Exemplified by George Lakoff and Mark Johnson, Metaphors We Live By (Chicago: University of Chicago Press, ).
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bodily experience. More remarkably, it feeds back from the cosmos into views of the body, which are in turn constructed as a landlike space: consider again Aetius, IX, , already quoted: ‘nature has created the stomach (gastēr) as a storage place (tameion) for food, just like earth for plants (ōs tēn gēn tois phytois)’. This is particularly evident when we consider discussions of ‘fluxes’, the rhooi crossing the koiliē, an eminently Hippocratic image of the body. At Loc. Hom. – (– Craik = .– L.), for example, the cavity of the body is drenched and crossed by ‘fluxes’ of various natures and kinds, determining physiology and pathology in turn, and vocabulary of flux (xyrrein, epirrein, phooi, lymata, reumata) recurs repeatedly (Loc. Hom. , , –, – Craik = .–, .– L.). Fluxes crossing the body and determining health are also very much in the foreground in Glands ( Craik = .– L.) and De Morbo Sacro with reference to the brain. As we move further into tropes endowed with ethical meaning, there is also the imagery of the earth as a rich and fertile repository, a maternal ‘belly’ whose excessive exploitation epitomizes hybris. The earth as a resource concealing treasures is a topos in classical anthropologies – cf. Prometheus Bound –: ‘now as to the benefits to men that lay concealed beneath the earth (ἔνερθε δὲ χθονὸς κεκρυμμέν’ ἀνθρώποισιν ὠφελήματα), bronze, iron, silver, and gold; who would claim to have discovered them before me?’ – and has a long moralistic afterlife. Digging for gold as symbolic gorging is key to the tirade by Democritus in the pseudepigraphic Hippocratic letter (.– Smith), since the activity is connected to greed and exploitation, ‘cutting the veins’ of the earth in search of riches: they have no shame at being called happy for digging gaping holes (χάσματα γῆς) in the earth using the hands of chained men, some of whom have died from the collapse of porous earth . . . they search for gold and silver, seeking out tracks and scrapings of dust (ἴχνη κόνιος καὶ ψήγματα ἐρευνῶντες), gathering sand from here and there and excising earth’s veins for profit (τῆς γῆς φλέβας ἐκτέμνοντες ἐς περιουσίην), even turning Mother Earth into lumps (βωλοκοπέοντες). But it is one and the same earth that they walk on in wonder.
A system of references increasingly centered by literary contemporary scholarship, in the spirit of the ‘environmental humanities’. Places in Man (Loc.Hom.), ed. and trans. by Elizabeth M. Craik (Oxford: Oxford University Press, ). On the meaning of technology, metallurgy, and the exploitation of resources, see Emmanuela Bakola, ‘Space, Place and the Metallurgical Imagination of the Prometheus Trilogy’, in Greek Theatre and Performance Culture around the Black Sea, ed. by David Braund, Edith Hall, and Rosie Wyles (Cambridge: Cambridge University Press, ), pp. –. Cf. again Ov. Met. I, – for the moralistic topos.
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With its holes and bumps, the model is bodily and medical. The belly is the greatest receptacle, source of life, and storage place of resources also in the Hippocratic Regimen . ( Joly-Byl = . L.): The belly (koiliē) is made the greatest, a storage chamber (tameion) for dry water and moist, to give to all and to take from all, the power of the sea, nurse of creatures suited to it (zōēn entrophōn trophon), destroyer of those not suited. . . . in which things are carried and come to light (pheromena es to phaneron aphikneitai ekaston moirēi), each according to its allotted portion.
Galen is happy to use the image at De symptomatum causis (.– K), tracing an open analogy between the human body and the earth, and between the human animal and plants: Nature created the stomach/gastēr as a receptacle/storage place for food, like the earth for plants. It also gave it a feeling of awareness/sense/perception of want, so that animals spurred (by it) towards food and drink could replenish themselves (ἡ φύσις ἐδημιούργησε μὲν καὶ τὴν γαστέρα ταμεῖον τροφῆς, οἷόν περ τὴν γῆν τοῖς φυτοῖς· ἔδωκε δὲ καὶ τῆς ἐνδείας αἴσθησιν, ἵν’ ἐξορμῶντα τὰ ζῶα πρός τε τὴν ἐδωδήν τε καὶ πόσιν ἑνὶ χρόνῳ πληρῶνται).
Conclusion I have not, I hope, strayed too far from the topic of medicine and literature. These tortuous itineraries have shown how, at the beginning of the Greco-Roman literary and scientific tradition (localized in terms of genre and conventions in Homer and fifth-century prose and poetic texts), the embodied matrix which provides models for philosophical inquiry and ethical reflection can only be fully understood by considering the terminology and hermeneutic strategies adopted by medical texts, and vice versa, as a two-way loop. One can only tackle this topic, anatomy and guts – which in the modern world would be of exclusively medical relevance – by placing medicine and other literary sources in dialogue with one another. At later stages in our tradition, the interchange between medicine and literature will become self-conscious, mimetic, parodic, and intertextual (e.g. in Plutarch and Christian authors, and certainly in Ovid, already quoted). But in the classical period, the common roots of
Poetic cosmologies appropriate these deep-seated models – cf., representatively, Ovid’s Met. , –. Cf. Reviel Netz, Scale, Space and Canon in Ancient Literary Culture (Cambridge: Cambridge University Press, ). See Chiara Thumiger, ‘Ovidius medicus. The exploration of the body in the Metamorphoses’. Maia, forthcoming ().
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medical reflection and other cultural products are still much deeper than the diverging branches are high. In the example chosen in this chapter, ‘guts’, the indeterminacy of early observations about the interior of the abdomen, privileging volume and texture rather than organic items and structures, influenced medical and natural-philosophical approaches, which built their observations around the cavities, the koiliai, as the centre of life. These in turn invited extension to the environmental, cosmological, and metaphysical spheres, which fed back into the medical view of the belly, its vital and almost cognitive powers, and its fundamental importance for animal life. All these, finally, were enriched with ethical and political valence by virtue of their connection with key themes such as goods and possessions, nutrition, survival, and exploitation.
On ancient guts and cognition, in dialogue with current neuroscientific concepts of a ‘gut brain’, see Chiara Thumiger, Guts and Their Diseases in Greco-Roman Biology and Medicine. A Handbook (forthcoming).
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Medieval Affect, The Book of Margery Kempe, and Medical Treatments of the Embodied Soul Holly A. Crocker
Although medieval affect has rightly been associated with ‘affective piety’, a form of religious devotion focused on the suffering body of Christ, this essay details the foundational place of affect for medical treatments of body and soul. The figure of ‘Christ as physician’ has long been held to be an elaborate metaphor; yet, as a myriad of medical treatises attest, Christ’s healing power was vital to medical treatments because the soul was accepted as the driving force of physical health across the Middle Ages. Because the medieval soul was fully embodied, affects of love, joy, fear, and anger played a practical part in diagnosing or treating a patient’s health. In late medieval medical manuals, along with forms of living and confessional forms, care for bodies and souls draws on a common affective vocabulary. Rather than seeing one form of affective discourse as spiritual and the other as practical, this chapter concludes by briefly turning to The Book of Margery Kempe to take seriously her claim that Christ heals via an affective intensity that transforms her body and soul. The therapeutic domain of affect unites body and soul, spiritual and practical, in late medieval medical writings.
Affect and Emotion, Medicine and Confession In what follows, I draw on several areas of medieval scholarship, each of which is more complex and nuanced than this chapter’s compact account acknowledges. I am not a historian of medicine, confession, or the practical
For a comprehensive overview of affective piety, see Mary Agnes Edsall, ‘Affective Piety’, Wikipedia [accessed June ]. Thanks to Edsall for this generous contribution to public knowledge. See Damien ouquet and Piroska Nagy, ‘Medieval Sciences of Emotions during the Eleventh to Thirteenth Centuries: An Intellectual History’, OSIRIS, , (), –. Alastair J. Minnis, Medieval Theory of Authorship, nd edn (Philadelphia: University of Pennsylvania Press, ), pp. –, observes this distribution of basic affects in a number of medieval authors.
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arts. Nonetheless, my own research area, medieval affect, intersects with all these fields via a durable, flexible image of ‘Christ as physician’. Jesus’s healing powers derive from ancient thought, and defined pastoral discourse beginning with Gregory the Great’s Liber Regulae Pastoralis. After the fourth Lateran Council of , which mandated yearly confession for all Christians with the decree of Canon , Omnis utriusque sexus, the Western Church instituted a sweeping pedagogical programme designed to prepare souls for confession. Much of this literature describes confession as a type of cura animarum, or ‘cure of souls’. Historians of medicine have largely set aside the elaborate discourse of treatment and healing circulated by this era’s pastoral and penitential literatures; that is because, as Masha Raskolnikov details, the language of ‘sowlehele’ was densely figurative. Even literatures that drew more explicitly on an emerging vernacular discourse of medicine could be said to mine such sources for poetic power, as Jeremy J. Citrome establishes and Julie Orlemanski elaborates. Yet the spiritual transformation that late medieval literary texts depict using medical metaphors arises from a lengthy stylistic tradition, which, as Rita Copeland’s magisterial work affirms, relies on emotion as much as affect. The rhetoric of medicine – specifically the complex motif of Christ as physician – links the cure of souls to powerful feelings. As the fourteenthcentury popular preaching manual, the Fasciculus Morum, declares, ‘Christ comes as a good physician to heal us.’ Figures unifying care with cure are central to the developing style of devotion known as ‘affective piety,’ which emerged beginning in the thirteenth century, and which ultimately encouraged lay participation in religious rituals associated with Christ’s passion. But it increasingly appears that affective devotion played a larger part in the practice of medicine than scholars have hitherto acknowledged. Many
Gregory argued priests should be ‘physicians of the heart.’ See Clare McGrath-Merkle, ‘Gregory the Great’s Metaphor of the Physician of the Heart as a Model for Pastoral Identity’, Journal of Religion and Health, , (), –. See E. A. Jones, ‘Literature of Religious Instruction’, in A Companion to Medieval English Literature and Culture, c. –c. , ed. by Peter Brown (London: Wiley-Blackwell, ), pp. –, for a detailed survey of how this canon was put into practice via literatures meant to instruct the laity in the basic elements of the faith. Masha Raskolnikov, Body against Soul: Gender and Sowlehele in Middle English Allegory (Columbus: Ohio State University Press, ). Jeremy J. Citrome, The Surgeon in Medieval English Literature (New York and London: Palgrave, ); Julie Orlemanski, Symptomatic Subjects: Bodies, Medicine, and Causation in the Literature of Late Medieval England (Philadelphia: University of Pennsylvania Press, ). Rita Copeland, Emotion and the History of Rhetoric in the Middle Ages (Oxford: Oxford University Press, ). Qtd. in Carole Rawcliffe, Medicine & Society in Later Medieval England (London: Alan Sutton, ), p. .
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medical texts draw upon literary ideas of Christ’s power to nurse and restore; Jesus’s role as healer provides an inspirational ideal. It also authorizes medicine as a practical art with spiritual significance; shaping souls via affective care, it turns out, improves physical and spiritual well-being. Arguably, however, the body in pain was more central to the rise of this spiritual movement; accordingly, it is the status of Christ’s suffering body that makes affect central to medieval medicine. More than just health, Jesus’s sacrifice pointed to the body’s precarity, and his suffering demonstrated the emotional dimensions of pain and death. Christ’s embodiment, above all, affirmed the close link between mortality and spirituality. If soul and body were integral, then the health of one affected that of the other. The body’s vicious habits could cause harm to the soul; in the debate poem, ‘þe Desputisoun Bitven þe Bodi & þe Soule’, the soul charges the body with pursuits that lead to the soul’s demise: ‘Whare be þine cokes snelle,/ Þat schuld go to grayþe þi mete/ Wiþ swot spices for to smelle,/ Þat þou were neuer ful to frete, To make þi foule flesche to swelle, Þat wilde wormes schal now ete?’ [Where are your quick cooks, who should work to prepare your food, with sweet smelling spices, so that you were never sated, and which made your foul flesh swell, so that now wild worms shall eat?] It was equally true, however, that the soul’s maladies might lead to physical destruction, as the body counters: ‘Þou scholdest fram schame ous haue yschilt’ [You should have protected/defended us against shame]. Because the body was ensouled, the soul’s movements and orientations made a difference to physical health. Moreover, in the most fundamental imitatio Christi, enduring bodily pain could improve the soul’s spiritual condition. The question of how soul and body disposed one another, however, yields a complex answer that turns on the relationship between emotion and affect, and that is pertinent to affect’s role in medieval medicine. By the high Middle Ages, medieval thinkers had devised a sophisticated moral psychology, which divided parts of the soul into sensitive and intellectual domains. The emotions belonged to the sensitive part of the soul, and were stirred by the senses; the affects resided in the intellectual part of the
‘þe Desputisoun Bitven þe Bodi & þe Soule’, The Auchinleck MS, NLS Adv MS .. (ff.vb– ra), lines –. ‘Desputisoun’, line . See Holly A. Crocker, ‘Medieval Affects Now’, Exemplaria, , (), –, for an overview. See also E. Ruth Harvey, The Inward Wits: Psychological Theory in the Middle Ages and the Renaissance (London: Warburg Institute, ); John Dryden, ‘Passions, Affections, and Emotions: Methodological Difficulties in Reconstructing Aquinas’s Philosophical Psychology’, Literature Compass, , (), –; and Simo Knuuttila, Emotions in Ancient and Medieval Philosophy (Oxford: Clarendon, ), for more detailed studies.
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soul, and were moved by sensations, but were ideally driven by will and governed by reason. The soul’s order was notoriously fraught; from Augustine’s theorization of the two wills, to entire literary works dedicated to the conflict between Reason and Sensuality: the connection between body and soul meant that the affects, like the emotions, were among the many moving parts central to health across the Middle Ages. Affects and emotions were connected, but they were not the same in medieval theorizations. Confusion arises because the same terms could refer to emotions and affects: hate and fear, like love and joy, could refer to different affects or emotions. The emotions were stirrings, disturbances caused by sensation; by contrast, the affects were dispositions, orientations produced by habituation. Affects were more durable, though ‘affectio’ might also mark an immediate irruption of individual temperament. Emotions, too, might become habits, especially since they could be repeated or practised. A person could feel the emotion of hate, but the affect of hate arranged a person’s soul. Near the opening of the influential Regimen sanitatis Salernitanum (ca. twelfth or thirteenth century), the poem advises: ‘Shun busy cares, rash angers, which displease; Light supping [eating], little drink do cause great ease.’
(E)motions of the Soul Because the body was ensouled, and the soul was embodied, emotions and affects were central to medieval medical practice. The language of
Martina Stepinova, ‘Aquinas’ Solution of Aristotle’s Incontinent Man and Augustine’s Two Wills’, New Blackfriars, , (), –. John Lydgate, The Assembly of Gods: Or, The Accord of Reason and Sensuality in the Fear of Death, ed. by Oscar Lovell Triggs, EETS, , (London: Kegan, Paul, Trench & Tru¨bner, ). Modern writers define affect as ‘intensities’ that circulate between and within bodies; in recent accounts, affects are separated from emotions, but medieval thinkers, because they located affects within the soul’s structure, saw affects and emotions as related, even connected. For modern treatments, see Brian Massumi, Parables for the Virtual: Movement, Affect, Sensation (Durham: Duke University Press, ); Sara Ahmed, ‘Affective Economies’, Social Text , , (), –; and Sianne Ngai, Ugly Feelings (Cambridge, MA: Harvard University Press, ). Mark Amsler, ‘Affectus in Medieval Grammar’, in Before Emotion: The Language of Feeling, –, ed. by Juanita Ruys, Michael Champion, and Kirk Essary (London: Routledge, ), pp. –. Monique Scheer, ‘Are Emotions a Kind of Practice (And Is That What Makes Them Have a History)?: A Bourdieuian Approach to Understanding Emotion’, History and Theory, , (), –. Faith Wallis and Paul Edward Dutton, ‘Lifestyle Advice for All: The Salerno Regimen of Health’, in Medieval Medicine: A Reader, ed. by Faith Wallis and Paul Edward Dutton (Toronto: University of Toronto Press, ), p. . Stephen Medcalf, ‘Inner and Outer’, in The Later Middle Ages, ed. by Stephen Medcalf (London: Methuen, ), pp. –, suggests that ‘the medieval classification is psychophysical’ (p. ). Also see, Elizabeth Robertson, ‘Medieval Medical Views of Women and Female Spirituality’, in
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medicine, it is worth noting, was highly attuned to affect, and is deeply emotive despite its practical bent. In the Prologue of the Liber Uricrisiarum, the earliest academic medical text written in Middle English (ca. late s), Henry Daniel offers a rhetorical apologia – for his art, for English – that might befit any poetic work of the day: ‘[F]or Y am nouþer witty ne wise of this tonge . . . no science may sufficiently be schewede in þis tonge, s. English . . .’ [For I am neither wise nor witty in this tongue . . . no science may be sufficiently disclosed by this language, that is, English]. Not only are formal medical texts written in verse – the Salerno Regimen features hexameter – compilations and fragments also frequently use verse to make medical teaching more memorable and authoritative. Hannah Bower’s exhaustive and transformative investigations of Middle English remedies dispatch the idea that medical writings, even the most mundane, are non-literary or under-formalized. As a particularly notable example, Bower includes a passage from a fifteenthcentury verse remedy that shows the importance of poetics to medical writings: ‘And in metir I it make raþer þan in prose/ þat it be lustiere to lere & liȝtere to kunne’ [And I compose it in meter rather than in prose; so that it will be more fun to study and easier to know (remember)]. Sara Star demonstrates the inventiveness, as well as the sonic texture of Henry Daniel’s Liber Uricrisiarum. Medical discourse not only uses affect, it also addresses it. Similar to other medical writings of the era, Daniel’s theory of the body is humoural, which meant that the body was divided into four fundamental elements (or humours) – blood, black bile, yellow bile, and phlegm – which produced good health in proper balance. Accordingly, Daniel cautions against feelings that might lead to imbalance, or that might diminish or intensify certain of the body’s humours. Given that each person was believed to have a different ‘complexion,’ or a particular admixture of humours that might dispose a person to different habits, and so render a person susceptible to specific ailments, Daniel’s emphasis on balance and proportion was crucial. Yet, as his instructions also make clear, good health was also an active process of personal cultivation. In his account, a ‘passion in þe soule,’ especially a feeling associated
Feminist Approaches to the Body in Medieval Literature, ed. by Linda Lomperis and Sara Stanbury (Philadelphia: University of Pennsylvania Press, ), pp. –, for a discussion of how soul and body were united in women’s religious experience. Henry Daniel, Liber Uricrisiarum: A Reading Edition, ed. by E. Ruth Harvey, M. Teresa Tavormina, and Sarah Star (Toronto: University of Toronto Press, ), p. . See Hannah Bower, Middle English Medical Recipes and Literary Play, – (Oxford: Oxford University Press, ), p. , for an inscription from BL, MS Sloane pp. –, v–r. Sarah Star, ‘The Textual Worlds of Henry Daniel’, Studies in the Age of Chaucer, (), –.
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with sin, such as ‘ire, wraþ,’ can lead to sickness. Illness in the soul can cause consumption over time: ‘[it is] caused of passion of þe soule, os of lastand wraþ’ [it is caused by a passion of the soul, such as lasting wrath]. Cures for different maladies of the soul, accordingly, involve restoring the soul’s proper operation: ‘by reson þerof þe soule mai sufficiently wirk and fulfille his spiritual operacions for þe wirkynges of þe soul ar spiritual’ [by reason thereof the soul may sufficiently work and fulfil its spiritual operations, for the workings of the soul are spiritual]. In formal medical texts, emotional state was one of the conditions the practitioner was meant to assess in making a diagnosis, because ‘mental affections’ were one of the six non-naturals in ancient and medieval medicine. When the physician Peter Fagarola of Valencia wrote a letter of advice to his sons in the s, he addressed the ‘accidents of the soul’: Accidents of the soul have the greatest influence, such as anger, sadness, and love of women, fear, excessive anxiety: concerning all which I say nothing more than that you [should] avoid all passions of the soul harmful to you and enjoy yourself happily with friends and good companions, and cultivate honesty and patience, which bring more delights to the soul, and especially if you love God with your whole heart . . .
As Naama Cohen-Hanegbi explains, ‘the notion that the body is the locus of emotions was pivotal to medical consideration of the “accidents of the soul”’. The mixture of spiritual and practical advice is therefore not unique, but is part of an elaborate regimen that, in Cohen-Hanegbi’s words, ‘provides an account of the vocabulary with which physicians of the thirteenth to fifteenth centuries engaged in thinking about the occurrences of the soul’. Other, more ‘homely,’ medical writings are equally interested in affect, especially how different emotions move body and soul to conditions of health and sickness. In the irregular fifteenth-century verse inscription
Daniel, p. . Daniel, p. . Daniel, p. . Peregrine Horden, ‘A Non-natural Environment: Medicine without Doctors and the Medieval European Hospital’, in The Medieval Hospital and Medical Practice, ed. by Barbara S. Bowers (Aldershot: Ashgate, ), pp. –; and Daniel McCann, Soul Health: Therapeutic Reading in Later Medieval England (Cardiff: University of Wales Press, ), who explores how devotional treatises create a ‘medicine of words’ via the non-naturals (p. ). ‘Advice Customized: Physician of Valencia Advises His Sons’, in Medieval Medicine: A Reader, ed. by Wallis and Dutton, p. . Naama Cohen-Hanegbi, ‘A Moving Soul: Emotions in Late Medieval Medicine’, OSIRIS, , (), – (p. ). Naama Cohen-Hanegbi, Caring for the Living Soul: Emotions, Medicine and Penance in the Late Medieval Mediterranean (Leiden: Brill, ), p. .
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Medieval Affect
from MS. Magdalene College Cambridge Pepys , different parts of the body influence a person’s faculties, including the emotions: ‘the liver maketh a man to love’. Conversely, across John Trevisa’s translation of de proprietatibus rerum, the soul’s passions furnish a link between macroand microcosm in this sprawling encyclopedia: Of the vertue spirituall, commeth wrath, fighting, indignation, spite, and such passions, that arise in brute beastes through mouing of the spirital vertue with vehemencie, & without discretion: but in men such passions be ordred and ruled by a certaine reason of wit. And of the vertue spiritall or vitall, that is said shall suffice.
Taken together, medical texts from the canonical to the ephemeral were invested in the ways that feelings joined body and soul in sickness and in health.
Affects and the Spiritual Habitus According to John Lydgate’s Dietary, a popular fifteenth-century conduct poem promoting a regimen of health, the most important aspect of selfcare was the practice of Christian piety: ‘Fyrst at thy rysing to God do reverens.’ Emotions involved in devotion are important to health, according to a host of medical writings in the Middle Ages. The Cyrugie of Guy de Chauliac insists that the patient ‘be pacient of suffrynge in himself, for pacience ouercometh malice, as it is saide in anoþer scripture’. Prayer is not just a petition for healing; importantly, prayer tunes affect, shaping the soul in a fashion that opens the sufferer to care, and to remedy thereby. The intimacy of the relationship between body and soul meant that spiritual exercises – cultivations of devotion that had nothing to do with medieval medicine – were nonetheless important to a patient’s health and potential for healing.
Digital Index of Middle English Verse , p. . Batman vppon Bartholome his booke De proprietatibus rerum, newly corrected, enlarged and amended: with such additions as are requisite, vnto euery seuerall booke: taken foorth of the most approued authors, the like heretofore not translated in English. Profitable for all estates, as well for the benefite of the mind as the bodie. . London, Imprinted by Thomas East, dwelling by Paules wharfe. Book II. Chapter (p. ). John Lydgate, ‘Item : The Dietary’, in Codex Ashmole : A Compilation of Popular Middle English Verse, ed. by George Shuffleton, TEAMS Middle English Series (Kalamazoo: Medieval Institute, ), line . The Cyrurgie of Guy de Chauliac, ed. by Margaret S. Ogden, vol. , EETS, (London: Oxford University Press, ), p. .
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For reasons that have only incidentally to do with medicine, a large body of devotional and spiritual writing sought to cultivate and direct the affects by means of a soul-forming habitus, or a programme of behaviour that would instil and perfect any number of individual virtues. Yet with increased participation in lay piety, particularly via modes of affective devotion, what had been a set of practices designed to cultivate religious virtue among a cloistered, clerical elite became more widely available. Katharine Breen points to the ‘crisis in habit’ that accompanied this expansion beyond monastic cultures. Yet as Nicole R. Rice details, devotional literatures that promoted lay piety were equally invested in cultivating a spiritual habitus. As Daniel McCann affirms, these writings are pertinent to medicine, not just because they are invested in shaping the soul’s affects via the development of an ethical habitus; spiritual literatures use medical metaphors, and, in many cases, devotional texts proffer advice meant to promote health and healing. Henry of Lancaster’s Anglo-Norman account of penance and spiritual healing, Le livre de seyntz medicines (The book of holy medicines) (ca. ) represents a complete synthesis of medical and spiritual discourse. Making liberal use of the Christus medicus motif, Henry presents sin as a series of wounds. Henry’s text is breathtaking for its combination of therapeutic remedies with devotional practices. In describing a cure for madness, which, Naoë Kukita Yoshikawa observes, is directly consonant with other medical manuals, Henry advises the patient/penitent to focus on the therapeutic object (which, for this malady, required a young cockerel to be killed, gutted, and split) in the same fashion as a worshipper would focus on Christ’s body during a passion meditation: Now, if I am to be cured of this delirium, I shall have to take this cockerel, thus prepared, and place it on my weak head, to lift my spirits, and to put me in my right mind . . . And the red cockerel is you, most sweet Jesus, who are, as I have said beforehand, physician and remedy, so that I beg you, dear sweet Master, that I might firmly think upon the red cockerel, and through its power recover my wits in such a way that I think of nothing unless it be in you or of you or for you.
Katharine Breen, Imagining an English Reading Public, – (Cambridge: Cambridge University Press, ), pp. –. Nicole R. Rice, Lay Piety and Religious Discipline in Middle English Literature (Cambridge: Cambridge University Press, ), p. . McCann, pp. –. My analysis of this text follows Naoë Kukita Yoshikawa, ‘Holy Medicine and Diseases of the Soul: Henry of Lancaster and Le Livre de Seyntz Medicines’, Medical History, , (), –. Qtd. in Yoshikawa, p. .
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In directing a devotional focus to the healing power of Christ’s suffering body, this remedy shows not only how spiritual and physical cures coincide, but also how these interconnected states of health rely on the patient/ penitent’s emotional condition, viz., a ‘right mind’. Elsewhere, as Henry of Lancaster makes clear, habits of contrition are important to ‘heal the foul wound of my mouth . . . by true confession, with heartfelt sorrow’. Likewise, in Robert Brunne’s ‘Handlyng Synne’ (begun after ), Christ’s ability to heal the sickness caused by sin is connected to the penitent’s development of specific affects. In this popular spiritual manual, the confessant must cultivate ‘gode wyl and hertë fre,’ assuming humility before the priest, who takes on the role of spiritual physician: ‘He þat wyl hys helë seke,/ To hys prest he mote be meke.’ The discussion of the seven deadly sins is replete with language of ‘hele,’ but as the entries detailing the pitfalls of gluttony and sloth make clear, diet, exercise, and emotion dispose the sinner to a life of spiritual vigour and virtue. The connection of body and soul is so commonplace that it is impossible to speak of the health of one without the other: ‘Ete ne drynk but þat nede ys./ who so doþ hyt oute of mesure,/ Hele of body may nat dure,/ And to hys soule, hyt ys dedly synne.’ Training in feeling, which Sara McNamer connects to ‘emotional scripts’ featured in pastoral and spiritual instruction, constitutes a larger affective technology in the Middle Ages. Orienting oneself towards healthy practices of body and soul is essential to the ordering of affect that established a virtuous habitus – from food and drink to meekness and measure. Many of these texts, like the kinds of compassion they encourage using a medicalized vocabulary, are directed specifically towards women. This gendered particularity should come as no surprise, since, as the transformative work of Monica H. Green affirms, medieval women were associated with everyday forms of medical care. From the household to
Qtd. in Yoshikawa, p. . Robert Mannyng, Robert of Brunne’s ‘Handlyng synne’, ed. by Frederick Furnivall, EETS, (London: K. Paul, Trench, Tru¨bner, –), pp. , –. Mannyng, pp. –. Sarah McNamer, Affective Meditation and the Invention of Medieval Compassion (Philadelphia: University of Pennsylvania Press, ). McNamer, pp. –. Monica H. Green, ‘Women’s Medical Practice and Health Care in Medieval Europe’, Signs, , (–), –; Monica H. Green, ‘Documenting Medieval Women’s Medical Practice’, in Practical Medicine from Salerno to the Black Death, ed. by Luis Garcia-Ballester and others (Cambridge: Cambridge University Press, ), pp. –; Monica H. Green, Making Women’s Medicine Masculine: The Rise of Male Authority in Pre-modern Gynaecology (Oxford: Oxford University Press, ). Monica H. Green, ‘Bibliography on Medieval Women, Gender,
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the hospital, women were associated with healing, so much so that Diane Watt details the importance of the image of Mary as physician after the Norman conquest of . Watt’s analysis reveals the therapeutic value of the Virgin’s compassion, but she also crucially connects that affective identification with laywomen’s practices of household medicine when she turns to the Paston women, whose letters provide a detailed view of daily care in fifteenth-century England: ‘And I remembere þat water of mynte or water of millefole [mint or milfoil essence] were good for my cosyn Bernay to drynke for to make hym to browke [tolerate food].’ As Katherine L. French acknowledges: ‘“Care” is a capacious concept that includes soothing worries, feeding, providing physical comfort, medical attention, nurturance, and training.’ Functioning as an action as well as an affect, the positive and negative valence of care is associated with medieval women. It was not only secular women who were expected to provide medical care to members of their households; religious women were important care workers in the Middle Ages. Holy women, including visionaries, gave spiritual advice that was meant to promote the health of body and soul. And they worked with the sick, most famously in the leprosaria where suffering defined the experiences of all. Sara Ritchey’s groundbreaking work on the mulieres religiosae from the low countries in the thirteenth century details their practices of medical care, including affective habits central to therapeutic treatment, both for patients and for the women themselves. The mulieres religiosae encouraged the sick to take up specific affects to increase the likelihood of cure; as Ritchey details, they ‘aroused salubrious affects such as joy, hope, or delight, and dispelled noxious ones such as fear’. Holy women prayed for those in their care, sharing an affective form of petitionary devotion linking divine, patient, and healer. Because women provided care outside the learned circles of formal medicine, feelings are central to medieval women’s powers of healing, so their place in the literatures of medicine and affect necessarily intersect.
and Medicine (–)’ [accessed August ]. Diane Watt, ‘Mary the Physician: Women, Religion, and Medicine in the Middle Ages’, in Medicine, Religion and Gender in Medieval Culture, ed. by Naoë Kukita Yoshikawa (Cambridge: D. S. Brewer, ), pp. –. Qtd. in Watt, p. . Katherine L. French, Household Goods and Good Households in Late Medieval London: Consumption and Domesticity after the Plague (Philadelphia: University of Pennsylvania Press, ), p. . Sara Ritchey, Acts of Care: Recovering Women in Late Medieval Health (Ithaca: Cornell University Press, ). Ritchey, pp. –.
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Affect, Medicine, and The Book of Margery Kempe No medieval text shows this gendered intersection of affect and medicine more clearly than The Book of Margery Kempe. The so-called spiritual autobiography by a fifteenth-century laywoman affirms women’s responsibility for household medicine. Quite famously, when her husband John falls, then deteriorates both mentally and physically, Kempe serves as a somewhat reluctant nurse. She frames the dirty drudgery of this work as spiritual restitution, as penance for the sexual enjoyment she took in her husband’s body when they were both young: ‘many tymys sche schuld an yrkyd hir labowr saf sche bethowt hir how sche in hir yong age had ful many delectabyl thowtys, fleschly lustys, and inordinat lovys to hys persone’ [many times she should have been irked at her labor save she bethought herself of how she in her young age had full many delectable thoughts, fleshly lusts, and inordinate loves for this person]. Here Watt calls attention to the tensions between Kempe’s status as woman religious and laywoman. Because Kempe took up a mode of performative piety outside the cloister, she scandalized those around her who expected women’s affective devotions to manifest themselves within the sanctioned structures of the Church. My interest resides in Kempe’s failure to manifest the feelings expected of wives in situations of carework. Her neighbours blame her for her husband’s fall, since the couple live apart: ‘And than the pepil seyd, yyf he deyd, hys wyfe was worthy to ben hangyn for hys deth, forasmeche as sche myth a kept hym and dede not’ [And then the people said, if he died, his wife was worthy to be hanged for his death, forasmuch as she might have kept him and did not]. In an earlier, memorable exchange, Kempe convinces her husband to enter a chaste marriage, in part with a cutting devaluation of her affection for him: ‘Forsothe I had levar se yow be slayn than we schuld turne agen to owyr unclennesse’ [Truly I had rather see you be slain than we should turn again to our uncleanness]. John’s response, ‘Ye arn no good wyfe’ [You are no good wife], condemns Kempe for her refusal to make herself open to him, to provide for his emotional and physical needs in a way that eclipses her own feelings and desires. When he becomes infirm, Kempe expends great effort in nursing John; nonetheless, her actions do not count as charitable, nurturing, or caring because she
Margery Kempe, The Book of Margery Kempe, ed. by Lynn Staley, TEAMS Middle English Texts Series (Kalamazoo: Medieval Institute, ), pp. I..–. All translations from Margery Kempe, The Book of Margery Kempe, ed. and trans. by Lynn Staley (New York: Norton, ). Watt, p. . Kempe, pp. I..–. Kempe, pp. I..–. Kempe, p. I...
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lacks the corresponding affects. As Kempe faces up to the challenges of carework, she recalibrates her feelings, imagining her service to her husband as love for Christ: ‘[she] toke it mech the mor esily and servyd hym and helpyd hym, as hir thowt, as sche wolde a don Crist hymself’ [[she] took it much the more easily and served him and helped him, as she thought, as she would have done Christ himself]. Through a deliberate practice of emotion, Kempe develops the Christian affects that she otherwise lacks. Across The Book of Margery Kempe, visions of care allow Kempe to practice feelings and cultivate affects. Kempe imagines herself as a nursemaid to St Anne, the Virgin Mary, and St Elizabeth; although she is not a healer, she tends each woman, giving the kinds of care that made up women’s everyday medicinal labour in medieval households. In a wellknown scene, she brings the Virgin Mary a ‘good cawdel’ [a good hot drink] to soothe her after Christ’s death, but Mary responds, ‘Do it awey, dowtyr. Geve me no mete but myn owyn childe’ [Do it away, daughter. Give me no food but my own child]. The practice of everyday medicine is central to Kempe; as Laura Kalas demonstrates, even the structure of the narrative accords with the medical organization of the ‘Life-Course,’ which she explains, relied on ‘the ancient connection between the four humours and the Four Ages of Man drawn by medical writers’. The final folio of the manuscript itself records a recipe for ‘dragges,’ which, Kalas observes, were ‘medicinal sweets: curative digestives . . . that were commonly used remedies for digestion. . .’ As recent work on Kempe establishes, it is increasingly clear that medicine is central to understanding Kempe’s experiences. That is because the medical practices featured in Kempe’s Book reveal the operation of a wider affective culture in late medieval England. Kempe’s participation in affective devotion has long been accepted. Her noisy weeping, along with her intense visions of Christ’s passion, shows how this form of piety shaped the spirituality of a prosperous laywoman such as Kempe. Tears, however, could have therapeutic value, insofar as they were a sign and a release of excess humours. Designed to display as well as to evoke piety, tears were salubrious, recalling Christ’s pain and
Kempe, p. I.. Kempe, I.. pp. –. Laura Kalas, Margery Kempe’s Spiritual Medicine: Suffering, Transformation, and the Life-Course (Cambridge: D. S. Brewer, ), p. . Kalas, p. . Encountering The Book of Margery Kempe, ed. by Laura Kalas and Laura Varnam (Manchester: Manchester University Press, ). Elina Gerstman, ‘Preface: “Going They Went and Wept”: Tears in Medieval Discourse’, in Crying in the Middle Ages: Tears of History, ed. by Elina Gerstman (London: Routledge, ), pp. vi–xx (p. vi).
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Mary’s grief. As Louise M. Bishop details, tears were associated with ‘femininity’s material wetness . . . [joining] the characterological and sensual components of passions and emotions, tied together in a material body/soul complex’. The uncontrollable ‘roryng’ [roaring] Kempe experiences, however, was subject to scrutiny, sometimes critique. Members of Kempe’s community see her weeping as a performance of hypocrisy, so much so that two priests take Kempe into a church to test whether she weeps so loudly in private. When they find she cries as ‘lowde er ellys lowder as sche dede whan sche was amongys the pepil at hom’ [loud, or else louder, than she did when she was among the people at home], they conclude her tears are a spiritual gift. But it is the stress on the body, and the upheaval of the soul, that worried religious writers who critiqued gestures of extreme devotion. These concerns are medicinal as much as spiritual; their intersection relies on affect, since a disordered soul could lead to physical dissolution. Kempe evinces ample knowledge of the interconnection of physical ailments and spiritual conditions. The sicknesses she reports – ‘Afftyrward God ponyschyd hir wyth many gret and divers sekenes’ [Afterward God punished her with many great and divers sicknesses] – prevent and galvanize her prayers and meditations. But the most comprehensive intersection of spiritual and medical health could be said to structure Kempe’s entire account; her early bout with madness is an affective crisis because the reconfiguration of her very soul is at stake during her illness. As Kempe details, after childbirth, she ‘went owt of hir mende and was wondyrlye vexid and labowryd with spyritys half yer eight wekys and odde days’ [went out of her mind and was wonderfully vexed and laboured with spirits for half a year, eight weeks, and some odd days]. The onset of sickness follows a failed confession, when her priest rebukes her before she can reveal her untold sin. Scholars have rightly detailed how Kempe’s mental deterioration arises from her spiritual upheaval. The struggle Kempe undergoes, I would only add, shows the power of affects to destroy as much as restore. Amid her crisis, Kempe details how devils convince her to abjure everyone and everything she loves. She is so ill that ‘Sche wold a fordon hirself many a tym . . .’ [in response to which] ‘sche was bowndyn and kept wyth strength bothe day and nygth that sche mygth not have hir wylle’ [she would have killed
Louise M. Bishop, Words, Stones, & Herbs: The Healing Word in Medieval and Early Modern England (Syracuse: Syracuse University Press, ), p. . Kempe, p. I... Kempe, p. I... Kempe, pp. I..–.
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herself many a time . . . [in response to which] she was bound and kept with strength both day and night so that she might not have her will]. Kempe’s affective disorder results in bodily harm; for medieval thinkers following Augustine, her corrupt will threatens her spiritual and physical health. So too, her cure illustrates the medicinal and spiritual power of Christus medicus in the Middle Ages. Although Kempe does not describe Christ as a physician, he appears to her to offer comfort, nurture, and care. When he asks a direct question, ‘Dowtyr, why hast thow forsakyn me, and I forsoke nevyr the?’ [Daughter, why have you forsaken me, and I forsook never you?], she is immediately recovered, so much so that, as Sarah Salih makes clear, she retrieves her identity when she asks for the keys that signalled the housewife’s management of the late medieval household. Kempe views this episode as a moment of healing, as her comfort for a woman suffering from madness after childbirth later confirms. Kempe does not see herself as a physician, but she is capable of healing across her Book. In each instance, the cure Kempe achieves comes from an ability to reform the soul of the sufferer. Like the Christ who visits her bedside, Kempe restores patients to themselves by means of an affective reformation that takes place within the sinful soul. Because medicine and religion intersected in the Middle Ages, affect was important to both in the everyday lives of Christian communities. Margery Kempe’s Book chronicles the influence of affective piety, but her account also demonstrates the reliance of this form of worship on ideas drawn from medieval medicine. Equally important, her own struggles with sickness, as well as her subsequent experiences with healing, reveal the importance of affective piety to medieval medicine itself. The conditions of the soul were part of overall health, and practices of piety designed to shape and tune the affects made a difference to the patient’s potential for cure. Affective practices were also part of therapeutic care; when Kempe offers comfort, or when she distributes discipline, she shows how arranging and reforming affects contribute to a patient’s recovery – both spiritual and physical. In this respect, The Book of Margery Kempe is far from unique; instead, this singular account by a fifteenth-century laywoman affirms the totalized intersection of affect and medicine in late medieval literatures.
Kempe, pp. I.., –. Kempe, p. I... Sarah Salih, ‘At Home; Out of the House’, in Cambridge Companion to Women’s Writing, ed. by Carolyn Dinshaw and David Wallace (Cambridge: Cambridge University Press, ), pp. –.
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Epidemiological Language in Robert Burton’s The Anatomy of Melancholy Jennifer Radden
Introduction A literary work ostensibly devoted to a medical subject, Burton’s Anatomy of Melancholy has preserved medical lore, popularized Galenic humouralism, and perpetuated neoStoic mental health ethics for more than four centuries. Its anatomical language and organization, and Burton’s selfidentification with the pre-Socratic anatomist-philosopher notwithstanding, it has been more often read as literature than medicine or science. While charming readers for so long, the exuberant prolixity and whimsical writing, as well as Burton’s astrology, theology, and outmoded physiology, have arguably served to distract readers from its useful insights about psychological health. In search of such effaced and neglected material, I want to start with observations that seemingly anticipate modern epidemiological findings concerning the ‘generality’ of melancholy: ‘[Melancholy] . . . being a disease so frequent . . . so often happening . . . in our miserable times, as few there are that feele not the smart of it . . . Being then as it is, a disease so grievous, so common . . . so universall a malady, an Epidemicall disease.’ A multitude of causes, including the social and political disorder around him, are offered for the extensive and increasing suffering Burton describes using ‘epidemic’ language. That language is a reminder of the ubiquity and variety of epidemics in England throughout his lifetime, with recurrent waves of influenza, typhus, dysentery, and
Acknowledgements: I am grateful to David McNeel for his critical reading of earlier drafts of this chapter and to helpful comments by our two volume editors. Robert Burton (–) spent his adult life at Oxford, completing successive editions of The Anatomy of Melancholy after the first in . Quoted passages in what follows are from the Third Edition (). Italics are in the original. Robert Burton, The Anatomy of Melancholy, ed. by Thomas Faulkner, Nicolas Kiessling, and Rhonda Blair, Vols. I–III: Text; vols. IV–VI: commentary by J. B. Bamborough and Martin Dodsworth (Oxford: Oxford University Press, /–). Burton I, p. .
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smallpox, as well as the endemic bubonic plague. Paying particular attention to Burton’s notions of ‘epidemic’ and ‘disease’, and against that historical background, I want to examine his claim that melancholy was, as he says, a universal and epidemic disease. I begin with an identification of some of the challenges attaching to any such inquiry, followed by analyses of ‘epidemical’, then ‘disease’ and ‘symptom’. Questions about the status of these ostensibly epidemiological assertions as medical science are explored, with particular emphasis on issues of spread and contagion. Next, Burton’s medical language of disease and symptom is introduced and shown to reveal some implicative contrasts with assumptions accepted today. With his depiction of an epidemic of distressing moods, Burton may seem to hold a mirror to our contemporary epidemics of depression and anxiety. This analysis leaves out much that is more consonant with our own times, however. Rather than revealing any matching epidemiology, and read selectively, the Anatomy instead points out alternatives to the way these allied conditions might be understood and remedied that allow us to recognize limitations in today’s medical approaches.
Preliminaries No effort to assess the validity of Burton’s claims about the occurrence of melancholy can be easy (not least because connotations of ‘epidemic’ are various, as we will see). Obvious challenges within the text itself include Burton’s literary ends and devices; others lie beyond, in the early-seventeenth-century cultural setting of its writing. Within the text, ‘Melancholy’ reveals a cluster of related meanings, naming the bilious black humour itself and also the affective states of disease with which imbalance of that fluid is associated. But some melancholy feelings – of sadness, sorrow, and fear – are simply our fate as human (and sinful) beings. Burton separates these into Melancholy in Disposition, referring to the lesser and passing states, and Melancholy in Habit, which is the state of disease. The latter is largely avoidable through the forms of self-care and preventive effort to which much of the book is devoted; the first is inescapable. Melancholy in this first ‘Equivocal and improper sense’
By some estimates epidemics accounted for per cent of reported deaths in seventeenth-century London, for example. In , , Londoners are said to have died of plague and in , ,, a sixth of its population. Keith Thomas, Religion and the Decline of Magic (Oxford: Oxford University Press, ), pp. –.
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Epidemiological Language in Robert Burton
of the Disposition is ‘the Character of Mortalitie’. In addition to these two ways of speaking about melancholy (as passing, normal moods and reactions and dangerous, chronic disorder), the term refers to personal tendencies and traits associated with temperament. While each of the four humours accounts for normal temperamental variation, people of melancholy temperament are thought more apt to succumb to the disease; unlike the Sanguine, Choleric, or Phlegmatic man, the Melancholic one was said to be timorous, sober, and contemplative. Melancholy is a cultural category quite as much as a medical one, blurring the line between illness and normalcy. This complex yet mostly consistent way Burton speaks of melancholy is confused by the jesting authorial voice of Democritus Junior, in his long prefatory Letter. Democritus Junior suggests, for example, that all who are mad are melancholy and all melancholy, mad. ‘Folly, Melancholy and Madness are but one Disease’, as he puts it. Although melancholy may progress to become madness, these two are distinguished elsewhere in the text, where madness is described as relatively more vehement and violent, while only melancholy exhibits the signature symptoms that Burton calls melancholy’s ‘inseparable companions’ of sadness and unfounded fears. And although many other writers conflate madness and melancholy, Burton explains, he will follow the newer thinkers (particularly du Laurens, Sassonia, and Montalto) who ‘handle them apart’. Elements less internal to the text further confound our reading of Burton’s epidemiological claims. Melancholy had been woven into Western cultural ideas from classical times. It was the subject of pictorial traditions with their own elaborate iconography (culminating by the sixteenth century in works such as Durer’s, with which Burton was familiar). A recurrent motif throughout Elizabethan drama and literature (in Shakespearean characters, for example), it had retained its earlier status as a framing cultural category. It had been a familiar and often valorized trait. Some melancholic suffering was apparently no more than a fashionable affectation. Writing within a year of the Anatomy’s first edition, John Donne observes: ‘Every distemper of the body now, is complicated with spleen, and when we were young men we scarce ever heard of the spleen. In our declinations now, every accident is accompanied with heavy clouds
Burton I, p. . Burton I, p. . In a later edition, this is claim of inseparability is slightly qualified (Burton, I, p. ). Burton, I, p. . On melancholy as an affectation see J. B. Bamborough, Introduction to The Anatomy of Melancholy by Robert Burton, ed. by Faulkner, Kiessling, and Blair, pp. viii–xxxvi.
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of melancholy.’ Donne describes epidemic proportions – but of what, we must ask? The poseur feigning fashionable spleen will differ from the true victim of melancholy, in Disposition or Habit. Yet we no more possess the means to ascertain the difference than Burton did. By contrast with the extensive cultural legacies attaching to melancholy, the medical record can be expected to be sparse. Still, little independent support for Burton’s claims has been found. Unlike other epidemics in Europe, the incidence of melancholy was not reported in civic documents; moreover, case materials, such as those of the astrologer Richard Napier practising during those times, fail to confirm the epidemic Burton describes. And any apparent increase in cases proportionate to population has today been explained by other factors such as growing interest in melancholy within moral-philosophical, religious, and political discourses devoted to the passions. Nor can the case records scattered through the Anatomy be taken as support for melancholy’s incidence, severity, or virulence. To illustrate symptoms, Burton alludes to others’ medical cases, sometimes without attribution, and usually briefly. Many of these represent the fears ‘without cause’ – the characterizations of melancholy states that trace to Hippocratic medicine – the misapprehensions, often reaching delusional proportions, which provided warrantless grounds for the individual’s distress. Lacking the detail of medical case records, these are told as anecdotes or folk tales, and make lively and amusing reading. There is the man who was ‘afraid to pisse, lest all the towne should be drowned’; a man who believed he was dead; the woman said to have thought she swallowed a serpent, and the man who believed his nose so big that he should ‘dash it against the wall if he stirred’. Serving the same literary purpose as Burton’s copious asides and frequent poetic and literary allusions, such tales leaven the text immeasurably. But their narrative appeal should probably discourage us from taking them as indicative of any epidemiological record. Rather than because of any preponderance of more flagrantly delusional symptoms such as those already described, the nebulous moods of dejection and
The recipient of Donne’s letter, dated October , is in some doubt. The collection that is the source of this text has it addressed to Henry Wotton. See Edmund Gosse, The Life and Letters of John Donne, Vol. II: Dean of St Paul’s (Eugene: Wipf and Stock, ). Michael MacDonald, Mystical Bedlam: Madness, Anxiety, and Healing in Seventeenth-Century England (Cambridge: Cambridge University Press, ). Angus Gowland, The Worlds of Renaissance Melancholy: Robert Burton in Context (Cambridge: Cambridge University Press, ). Burton, II, p. .
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Epidemiological Language in Robert Burton
sadness that were called ‘mopishness’ by the astrologer Napier, would make dull storytelling, and seem likely omitted on that account alone. His own case, Burton insists, provides a special and important kind of evidence also, for ‘that which others heare or read of, I felt and practiced myself, they get their knowledge by Bookes, I mine by melancholizing. Experto crede ROBERTO. Something I can speake out of experience . . . I would help others out of a fellow-feeling . . . .’ The passage is from the Letter, with its unreliable narrator, but elsewhere also, Burton hints at his own melancholy. Whether an accurate report or a literary device, these allusions to personal expertise offer the compelling immediacy and intimate sense of verisimilitude associated with ‘pathographic’ writing, invoking respectful sympathy from the reader over Burton’s stated distress.
Burton’s Method as Science To credit Burton’s observations as epidemiological data, assurance that he understood at least some of the fundamentals of empirical method would be a help. This will be constrained by his theological stance as a Christian churchman, however. (He makes clear that the materialistic determinism adhered to by some of the renaissance medical men whom he otherwise admires is incompatible with his belief in free will, for example.) Similarly, he must tread warily when it comes to the occult and magic. With their dangerous link to the dark arts, occult powers were a source of fascinated apprehension for any seventeenth-century Christian, particularly one writing about melancholy. Whether constraints from Burton’s theological beliefs would have reduced his actual understanding of scientific method may be unknowable. Yet that understanding has been challenged by commentators, most notably Lawrence Babb, who observes of Burton that: ‘Apparently it never occurs to him that firsthand observation and experience might be necessary to scientific competence . . . . [He] lacks . . . the experimental curiosity but also the critical skepticism which the true scientific thinker must have.’ Others have since reiterated or accepted this criticism, and despite its popularity, the Anatomy has been ignored or dismissed as medical science. We can understand some of why: Burton relies on humoralism and
Burton, I, p. . See Anne Hunsaker Hawkins, ‘Pathography: Patient Narratives of Illness’, Western Journal of Medicine, , (), –. Lawrence Babb, Sanity in Bedlam: A Study of Robert Burton’s Anatomy of Melancholy (Westport: Greenwood, ), pp. –.
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astrological lore as much or more than empirical approaches and is for the most part content to quote the findings of medical and philosophical authorities, rather than engaging directly with their observations. Moreover, the prolix and playful style and homely prescriptions are the antithesis of the sparer models valued in scientific writing. In addition to applauding the ancient medical writers whose legacy he sought so diligently to preserve, arguably, Burton acknowledges the nascent scientific attitudes emerging by his era through his extensive reliance on renaissance medical writing such as that of André Du Laurens and Johann Weyer. These authors – even as they retain the old anatomy and physiology, humoral language, and explanations – introduce real cases, observed first-hand and described in detail. And of course, the continued use of humoral language during early modern times also requires us to wonder how literally Burton is to be read. References to humoral substances and their effects were being transformed from literal descriptions to ubiquitous and powerful metaphors, even in the previous century. So Burton would not have been the first to stray from an entirely literal intention in his references to the black bile. His often teasing and satirical voice unsettles the reader over many aspects of medical lore, not least in his liberal references to humoral matters. Thus, while the intent of particular humoral descriptions and explanations remains unresolved, Burton’s attitude towards the newer physiology must be uncertain.
“Epidemicall” as Socially Contagious Like the polysemic ‘melancholy’, ‘epidemic’ connotes incidence measured by population, and speed, but also means, of spread, and some passages suggest that all three of these aspects of epidemics might have been intended when Burton described melancholy as an epidemical disease. Many epidemics in early-seventeenth-century England were, or were
This is arguably true of Weyer’s humoral language, for example. See Jennifer Radden, ‘De Praestigiis Daemonum: Another Look’, Melancholie: Modeziekte in de Middeleeuwen en Vroegmoderne Tijd Groniek, Historisch Tijdschrift, , (), pp. –. As metaphor, the lasting vitality of humoral language was remarkable. See The Cambridge History of Medicine, ed. by Roy Porter (Cambridge: Cambridge University Press, ). Indeed, humoral language and metaphors remain with us still in references to temperament – we talk of a happy temperament or a bad temper, of a jovial or saturnine disposition, of animal spirits or a heart moved by passion. And: ‘English-speakers still have to humor the whims of a temperamental colleague . . . and remain good humored throughout the week’, Noga Arikha, Passions and Tempers: A History of the Humours (New York: Harper Perennial, ), p. xix.
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Epidemiological Language in Robert Burton
believed to be, contagious through some form of interpersonal transmission. Their causes were fiercely debated during the renaissance, it has been explained, hastened by the appearance of syphilis in Europe towards the end of the fifteenth century, and giving rise to a ‘contagionist’ theory of disease by the sixteenth century. Its link with syphilis left the notion of contagion familiar and fearsome in early times, and burdened by moral associations as well as links to diabolism and magical transmission. Of the notion of contagion, it has been observed: ‘Everyone knew that diabolical maleficium was transferred from person to person: what else was “possession”? . . . “contagious disease” was, from the start connected in the popular mind with magic and diabolism.’ Ties with diabolism varied according to the affliction. Plague was explained by more natural causes, for example (airborne noxious vapours that combined with corrupt humours). Whether that left the condition a contagion was a disputed issue. With its multitude of causes (humoral, psychological, social, political, astrological, moral, and dietary), melancholy was subject to similar debates over its transmission. The condition was brought about by worldly (including astrological) circumstances, affecting the humours both directly and indirectly by way of the imagination, which in turn altered the person’s humoral state. Contrary to the exclusively material causes hypothesized by some of his contemporaries, Burton insists that the Devil can insinuate himself in minds and bodies susceptible to his influence, acknowledging as apt the old description of melancholy as the Devil’s bath. Aside from supernatural origins, Burton’s approach also permits stranger forms of natural transmission, with melancholy in one person giving rise to similar states in another while somehow bypassing reason. That such a mysterious but still natural transfer might be able to take place is early intimated with the prefatory warning that those who are ‘actually Melancholy’ should avoid ‘the Symptomes or prognostickes in the following Tract’ for fear that ‘he trouble or hurte himself’. If merely reading about melancholy could make one ill then it may be through a process somewhat akin to magic. And similarly analogous to – but
Porter, pp. –. Thomas, p. . Burton, III, p. . Such actions, Burton makes clear, take place only with God’s permission (Burton, I, p. ). Burton, I, p. . On this assumption, Burton’s writing and our reading function as healing charms, with language as curative, it has been noted. See Mary Ann Lund, Melancholy, Medicine and Religion in Early Modern England: Reading the Anatomy of Melancholy (Cambridge: Cambridge University Press, ).
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not – magic, the condition might be transferred between individuals by what today is known as ‘social’ contagion (to emphasize that no physical pathogens are responsible). To recognize the persuasiveness of this, it must be remembered that diseases for Burton and his contemporaries afflicted the soul and mind quite as much, and no more or less literally or exactly, than they did the body. So identifying melancholy as a disease would not preclude its having been transferred through some process bypassing conscious awareness and rational understanding. And resistance to mind to body transfers of this kind would not have been as strong as in the atmosphere created by the biomedical reductionism of today. Recognition of this sort of contagion appears in work on melancholy from the sixteenth century, including Burton’s ‘Wierus’, the much quoted and respected Low Countries physician Weyer. Melancholy is a condition to be named and interpreted to its subject with the greatest discretion because of the effect that its name alone could bring, Weyer observes. And the power of medicine sometimes ‘grows stronger as a result of the patient’s confidence in the doctor’, he points out, noting of talismans: the success of these cures does not derive from the charm; but the power of our mind is so great that if the mind convinces itself of some honorable object, and firmly perseveres in this object that it has conceived, it carries out and powerfully brings to completion the very object that it has conceived, provided that it does not encounter resistance or want of faith in the mind of the other person . . . . If it finds the other mind trusting and cooperative it will accomplish its purpose more quickly.
By insisting that beliefs, and the power of the mind, rather than charms could bring about healing, Weyer here resists the neoPlatonism of his onetime teacher Heinrich Cornelius Agrippa, for whom the world of natural objects was enchanted, and those charms and talismans possessed magical force. Such beliefs were widespread, it has been pointed out, many accepting ‘that stones might have hidden properties . . . and that some men could “fascinate” others by the emanations from their eyes’. Social contagions were particularly associated with the cloister. Weyer recommends isolation for melancholy nuns lest the others ‘be terrified by the strange and violent torments and . . . contract something of the disease’. Teresa de Ahumada of Avila, Weyer’s contemporary, makes
Johann Weyer, Witches, Devils, and Doctors in the Renaissance, trans by John Shea (Binghamton: Medieval and Renaissance Texts and Studies, ), p. . Thomas, p. . Weyer, p. .
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similar claims, enjoining abbesses from using the term ‘melancholia’ because of the risk of its spread within the group. The possibility of powers that, while natural, mysteriously bypass reason is threaded throughout the Anatomy. We find it in references to the seemingly undeniable results of witchcraft: effects that Burton thinks have been mistakenly attributed to unearthly causes. Thanks to renaissance doctors such as Weyer, the sources of apparently magical effects had increasingly come to be seen as natural and psychological, with accompanying attitudes that were more humane. Why do witches and old women fascinate and bewitch children, Burton asks? And the answer from many admired authorities, which he too accepts, is that ‘the forcible imagination of the one party, moves and alters the spirits of the other’. This process works through the passions, he explains, yielding real, if mysteriously produced, effects: ‘this imagination is the medium deferens of passions, by whose meanes they worke and produce many times prodigious effects’. Especially in passions and affections, he explains, the Imagination ‘shewes strange and evident effects’. Burton also recognizes the place of trust, and the role played by expectation in what are now known as placebo and nocebo effects. And in an era when solely medical and bodily remedies were largely ineffectual, successes would have often depended on their placebo power. This relative effectiveness is conveyed when, in a persuasively personal reference, Burton speaks of the healing arts practised by his own mother, famous for ‘good cures among diverse poore folks’. The amulet she offered these sufferers, he explains, seemed at first to be ‘most absurd and ridiculous, I could see no warrant for it’. But after reading that ancient medical authorities recommended such devices, he remarks: ‘I beganne to . . . give more credit to Amulets, when I saw it in some parties answere to experience’. Although seemingly undeniable and confirmed by (‘answering to’) experience, these strange effects were occurring in a setting characterized by uncertain, contradictory, and troubled attitudes, it must be
See Radden. For earlier medieval evidence of these beliefs, see George Mora, ‘Mental Disturbances, Unusual Mental States and their Interpretation during the Middle Ages’, in History of Psychiatry and Medical Psychology, ed. by Edwin Wallace and John Goch (New York: Springer, ), pp. –. Burton, I, p. . Burton, I, p. . Nocebo and placebo effects are acknowledged by modern-day psychological medicine. See, for example, Fabrizio Bennadetti, Placebo Effects (Oxford: Oxford University Press, ). These processes remain mysterious – yet as Burton saw, their effects are incontrovertible. Burton, II, pp. –.
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remembered. Folk superstitions about witches’ spells may have been facing scepticism, but neoPlatonist ideas about action at a distance were slow to disappear entirely, and Burton, who speaks of Agrippa quite respectfully, may not have been entirely immune from them. Still, his was a reasoned and observation-based conclusion when, of the role of imagination in healing, he remarks that it will ‘work upon itself’ to cause or aggravate melancholy symptoms, so that: ‘if a man is seen who is sick of some fearful disease, [men’s] apprehension and feare is so strong in this kind, that they will have the same Disease’. Moreover, sometimes nothing more than ‘a strong conceit or apprehension . . . will take away Disease’. Was melancholy a socially contagious disease? Some, like Weyer and Teresa de Ahumada, evidently thought so. And in Burton’s mind at least, a mysterious but wholly natural transfer, sometimes wrought solely through the medium of language itself, likely provided a partial explanation of the epidemic of melancholy symptoms he observed.
Familiar Medical Language of Disease and Symptom Reveals Underlying Assumptions Aside from the power of language to effect melancholy, Burton’s medical vocabulary reveals underlying assumptions about the nature of diseases and symptoms. Melancholy, he insists repeatedly, is a widespread, debilitating disease, one that when severe, is next to incurable. His ostensibly observational remarks about his subject are expressed in medical language, much of it entirely familiar to us today. But these assertions implicate aspects of the conceptual architecture of the Anatomy, without an understanding of which that familiarity may mislead. His conception of the embodied mind would have prevented Burton from adopting the modern idea that diseases might be exclusively bodily conditions. He could not accept, as many do today, that if used at all, ‘disease’ stands as a metaphor when applied to mental or spiritual disorder, leaving non-bodily diseases suspect things, better described in other ways and bordering on the imaginary and unreal. For Burton, and his contemporaries, diseases afflict the soul quite as much, and not in any important ways differently from the way they do the body.
Burton, I, p. . See Michelle Michael, ‘Renaissance Theories of Body, Soul, and Mind’, in Psyche and Soma: Physicians and Metaphysicians on the Mind-Body Problem from Antiquity to Enlightenment, ed. by John Wright and Paul Potter (Oxford: Clarendon Press, ), pp. –.
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Epidemiological Language in Robert Burton
Such contrasts between Burton’s use of familiar medical language and today’s direct us to assumptions that can be linked to show aspects of the work’s underlying structure. Because several of these assumptions are merely tacit, the following analysis is inferential. (It is also partial, omitting Burton’s theological beliefs, for example, by which melancholy traces to the Fall.) Although speculative, and incomplete in these ways, this reconstruction can be justified by its ability to explain and unite some key passages in the Anatomy, and render the relationship between the first and second Partitions into a coherent whole. It also makes particularly evident where caution is required to avoid a ‘presentist’ misreading. The body and mind possessed distinguishing attributes; in this respect Burton expresses a non-substantive form of dualism. A mutually interactive relationship joins minds and bodies: ‘the body works upon the mind . . . disturbing the soul and all the faculties of it . . .: so, on the other side, the mind most effectually works upon the body’. The mind’s embodiment is assumed in this and other passages and it seemingly avoids the substance version of dualism. But nor would his theological and philosophical beliefs permit Burton to accept the reductionism associated with today’s modern science. In this respect – adopting neither substance dualism nor reductionism – the Aristotelian metaphysics of the Anatomy leaves it largely orthogonal to contemporary analyses. And Burton gracefully – if obscurely – is able to sidestep implications of Cartesianism that dominated modern psychology and later came to frame the early psychiatry of the nineteenth century. (The recent emergence of network disease models and theories of embodied cognition are examples that each correspond more closely to Burtonian views.) Further contrasts between the assumptions guiding Burton and those of our contemporary medical science emerge through his focus on signs and symptoms of melancholy, which form the primary subject matter of the first two Partitions of the book: in the first they are described and explained, while the second offers their remedies and preventives.
For a fuller account of these reconstructive efforts see Christopher Tilmouth, ‘Burton’s “Turning Picture”: Argument and Anxiety in the Anatomy of Melancholy’, Review of English Studies, , (), –; Jennifer Radden, Melancholic Habits: Burton’s Anatomy and the Mind Sciences (Oxford: Oxford University Press, ). Burton, I, p. . See Denny Borsboom and Angélique O. C. Cramer, ‘Network Analysis: An Integrative Approach to the Structure of Psychopathology’, Annual Review of Clinical Psychology, , (), –; Lawrence Shapiro and Shannon Spaulding, ‘Embodied Cognition’, in The Stanford Encyclopedia of Philosophy, ed. by Edward N. Zalta (Winter ) [accessed December ].
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Burtonian symptoms are unlike symptoms associated with the etiological models of disease familiar from present-day medicine. Etiological models comprise an internal core phenomenon (or process) separated from, and giving rise to, more readily observable signs and symptoms, following a unidirectional causal sequence. The underlying factors causing signs and symptoms this way are today depicted as conditions of dysfunction, injury, imbalance, deficit, vulnerability, disorder, or, more recently, genetic risk. The etiological model is accepted or assumed, and widely thought to apply to all medical conditions whether they exhibit psychological or bodily symptoms. It remains fitting for many common diseases, the underlying source of which is sufficiently distinctive, stable, and predictable in its course to account for relatively discrete and identifiable syndromes. Projecting an etiological analysis on Burton’s explanation of the causes of melancholy is apparently incompatible with key passages, where the causal sequence is described as initiated by the imagination, including this one: To our imagination commeth, by the outward sense or memory, some object to be knowne . . . which he mis-conceiving or amplifying, forthwith communicates to the Heart, the seat of all affections. The pure spirits flocke from the Braine to the Heart, by certaine secret channels, and signifie what good or bad object was presented; which immediately bends it selfe to persecute, or avoid it; and withal, draweth with it other humours to helpe it: so in pleasure, concurre great store of purer spirits; in sadnesse, much melancholy blood; in ire, choler. If Imagination be very apprehensive, intent, and violent, it sends great store of spirits to, or from the heart, and makes a deeper impression, and greater tumult, as the humours in the Body be likewise prepared, and the temperature it selfe ill or well disposed, the passions are longer and stronger. So that the first steppe and fountaine of all our grievances in this kinde, is . . . Imaginatio, which misinforming the Heart, causeth all these distemperatures, alteration and confusion of spirits and humors.
Setting aside the humoral physiology, this passage indicates that because of its special power to ignite emotions that in turn engender bodily changes, the imagination can be seen to initiate the sequences resulting in melancholy symptoms; thus, the imagination, rather than any ‘distemperature of the body’ is the initiating cause of melancholy in such instances. Other
Limitations in the etiological model applied to psychological conditions are recognized in efforts to replace this ‘common cause’ account with network models (Borsboom and Cramer). Burton, I, p. . Without acknowledgement, Burton borrows here from Wright’s work Passions of the Mind in General, not only adopting Wright’s causal analysis, but his words and phrases.
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Epidemiological Language in Robert Burton
passages show humoral states and tendencies initiating these changes, affecting the passions and the imagination in turn. Burton explains that causation is multifactorial and bi-directional, and melancholy symptoms arise in each of these differing ways. The ancient association between melancholy and a disordered imagination lies at the center of his analysis, nonetheless – a point unequivocally stated in several places. ‘I may certainly conclude’, one of these begins, ‘[that] this strong conceit or imagination, is astrum hominis, the rudder of this our ship, which reason should steire, but overborne by phantasie, cannot manage, and so suffers it selfe and this whole vessel of ours to be overruled, and often overturned.’ In other ways as well, given ideas from our own time, Burton’s medical language challenges what we should expect. His causal hypotheses are imprecise, heterogenous, and shifting. Resisting any easy categorization, they range across theological, spiritual, astrological, behavioural, dietary, and humoral elements, which they influence and are influenced by. This leaves the symptoms of the disorder comparably innumerable, variable, and without clear boundaries. Also lacking is a consistent separation of symptoms from their causes. Due to the bidirectional loops uniting the bodily with the mental through affective states, the very same attributes can be both causes and symptoms of melancholy: Burton quotes Hippocrates, naming Sadness or Sorrow: ‘The mother and daughter of melancholy, her Epitome, Symptome, and chiefe cause, . . . . They beget one another, and tread in a ring, for Sorrow is both Cause and Symptome of this disease.’ His idea seems to be that through the effects of repetitive thought patterns on the person’s humoral properties, a passing sadness yields further gloomy feelings engendered by disturbed bodily states, so that the symptoms (of sadness) are at the same time further causes in the chain. The conception of disease in the Anatomy may at first appear to adhere to the model whereby all symptoms result from humoral states within the person, just as, in contemporary etiological models, causes are internal organic states. But such an analogy is doubly misleading. Not only does it fail to acknowledge the bi-directional aspect of Burton’s account, it also leaves unexplained passages that apparently form central aspects of Burton’s psychology and unite the first Partition with the recommendations and remedies that follow. The confusing plethora of melancholy’s innumerable symptoms and causes, ‘treading a ring’ with their bidirectional, mind to body and body to
Burton, I, p. .
Burton, I, p. .
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mind causation, have further consequences in the way this affliction must be viewed. Without an initiating and anchoring internal cause from which symptoms flow in an orderly direction, symptoms must be understood diachronically as they unfold through time, in the so-called natural history, or course, of the disease. In the early modern period disease was often regarded more as a process than an entity or ‘thing’, it has been observed, and likened to an evolving story offering a comprehensive narrative. This emphasis on disease course explains Burton’s repeated claims about the habitual nature of melancholy. Melancholy is depicted as resulting from repeated patterns of thought and behaviour that through time can become entrenched – a severe, chronic disorder that may eventually be difficult or even impossible to treat through application of the sufferer’s own efforts. The second Partition is devoted to preventives, remedies, and treatments, to be undertaken in an extensive, intensive multifactorial effort involving lifelong daily practices. Because of the lack of reliable medical treatments in the seventeenth century emphasis was on the placebo power of expectation and trust, as we saw. In addition, it had to be on self-help and more homely remedies, and these, derived in large part from the Six Non-naturals of ancient medical lore, form the basis of Burton’s prescriptions. With its stress on early prevention, the form of this part of the Anatomy has been compared with other popular self-help manuals from the previous century that were based on simplified Galenic medicine. It also has recognizable descendants in the self-help guides and alternative medicine approaches of our own era. Reconstructed through its underlying conceptual assumptions, the Anatomy’s first and second Partitions form a single, interrelated whole. And while confusing in their diversity and number, the preventive measures in the second Partition form a coherent picture when linked to earlier assertions stressing that melancholy as a state of disease results from adopting bad habits and lapsing from a daily regimen of self-care, including care of the passions. If neglected when it first occurs, melancholy becomes entrenched and eventually difficult to dislodge. What starts as melancholy the disposition, becomes through time the dangerous habituated melancholy (‘ill dispositions beget habits, if they persevere . . . habits are or turn to diseases’). Thus, melancholy must be withstood in the beginning, and ‘maturely resisted’, with ‘some contrary passion, good
Erin Sullivan, Beyond Melancholy: Sadness and Selfhood in Renaissance England (Oxford: Oxford University Press, ), p. . On such vernacular medical writing, see Lund. Burton, I, p. .
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Epidemiological Language in Robert Burton
counsel and perswasion’: ‘as those ancients hold, the nayles of it be pared befor they grow too long’. Much of the Anatomy can be read in these terms, as an effort to pare the nails before they grow too long and beyond any efforts at self-help. (Those ‘ancients’ were Hippocrates, Galen, and the admired Stoic philosophers, whose ideas, if not their influence, are reflected in some present-day cognitive therapy programmes.) As an attitude towards healthcare, this leaves the Anatomy both deeply antithetical to much of present-day clinical medicine, with its specific, targeted treatments for precisely identified conditions, yet at the same time close to public health and alternative medical approaches stressing preventative measures and self-help (respectively).
Conclusion The Anatomy is many things: a ludic satire, a medical encyclopedia, a selfhelp handbook, a guide to seventeenth-century Protestant theology, a work of cultural history, and more besides. What it certainly is not, is a reliable record of an epidemic of mental ill-health. What then can we learn from this version of literary medicine, and medical literature? First, its underlying conceptual architecture seems to show Burton’s account to be orthogonal to much medical thinking accepted today. To suggest or assume any compatibility, as some commentators have, is to risk imposing a misleadingly ‘presentist’ reading that fails to recognize the underlying structural tenets uniting the first and second Partitions. And second, read selectively, the work reveals aspects of the disordered moods Burton describes, their likely means of transmission, and approaches towards their prevention and care, each of which finds some resonance within the diverse and heterogenous medico-cultural landscape of today. Even as Burton admired the ancient medical wisdom he collected, for example, he took a sceptical view of the efforts of physicians in his own times. And despite increasingly biological conceptions of the mind prevailing in our own times, similarly sceptical attitudes towards medical psychology and its endeavours are to be found . The Anatomy’s ‘disease’ and ‘epidemic’ do not directly translate to present conceptions of these terms. (No more does ‘melancholy’ exactly correspond to present-day disorders of depression and anxiety, for all that ‘epidemic’ language is sometimes invoked to describe their incidence as
Burton, III, p. .
See Radden, Melancholic Habits, pp. –.
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well.) Yet the last several decades have seen the emergence of alternatives to prevailing models of diseases, symptoms, and remedies for mood disorder, several of them more compatible with the assumptions and approaches identified by Burton. Moreover, the Anatomy’s emphasis on the multitude of extra-bodily causes of mental suffering, on early prevention, the power of expectation, on habituation and self-help, also align surprisingly well with cultural attitudes and practices still to be found, many well beyond the clinic. While the meanings accorded to seemingly familiar terms such as ‘epidemic’, ‘disease’, and ‘symptom’ rest on underlying assumptions that leave them orthogonal to today’s standard medical conceptions, Burton’s uses find resonance both in recent theorizing and in the broader health culture of our own times.
On the relation between melancholy, depression, and anxiety, see Jennifer Radden, ‘Is This Dame Melancholy? Equating Depression and Melancholia’, Psychiatry, Philosophy & Psychology, , (), –.
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Illness and the Novel Aesthetics Hosanna Krienke
Writing what would become a famous critique, Henry James lampooned the aesthetic form of nineteenth-century novels, asking: ‘[W]hat do such large loose baggy monsters, with their queer elements of the accidental and the arbitrary, artistically mean?’ For much of the twentieth century, James’s phrase ‘large loose baggy monsters’ encapsulated what many critics viewed as the aesthetic flaws of nineteenth-century novels, particularly British texts. Indeed, these novels are long and meandering, with dozens of characters, several subplots, and multiple resolutions needed to tie up the story. Yet recent scholarship has re-evaluated such works, finding clear ideological and artistic aims in depicting ‘the accidental and the arbitrary’. Specifically, the sprawling form of the nineteenth-century British novel reflects a newly complex social landscape. In this century, British populations crammed into polluted industrial cities, railways and telegraphs linked far-flung locations, European imperialism devoured whole nations, and epidemics routinely swept the globe. Thus, the seemingly ‘loose’ and ‘baggy’ form of the novel demonstrates an emerging awareness of vastly interconnected – or, perhaps, hopelessly tangled – social ties in the modern era. In their seeming shapelessness, these novels gesture to the full range of relationships – global, local, intimate, even incidental – that undergird everyday life in the aftermath of the Industrial Revolution. Indeed, this chapter will argue that nineteenth-century literature shared with contemporary medicine the task of tracking, mapping, and ultimately narrating the many registers of the modern, socially embedded body.
Henry James, ‘Preface to The Tragic Muse’, in The Novels and Tales of Henry James, vol. (New York: Scribner’s Sons, ), pp. v–xxii (p. x). See Alex Woloch, The One Vs. the Many: Minor Characters and the Space of the Protagonist in the Novel (Princeton: Princeton University Press, ), and Narrative Middles: Navigating the Nineteenth-Century British Novel, ed. by Caroline Levine and Mario Ortiz-Robles (Columbus: Ohio State University Press, ).
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While this book as a whole demonstrates the many ways that literary forms swap ideas with the medical thought of their particular time and place, this chapter focuses on how this dynamic played out in nineteenthcentury Britain, where literary writers and medical experts alike aimed to depict the scale and scope of phenomena that affected whole populations. Victorian medical experts developed new methodologies for tracking societal health, including census reports, data on hospital mortality rates, even street-by-street disease maps. Aiming to provide a similarly holistic representation of the social sphere, Victorian novelists pioneered sprawling, multiplot narrative forms that situated characters within relational networks. Alex Woloch observes a fundamental shift in novelistic scope in this period: ‘[T]he nineteenth-century novel contains a greater quantity of characters than most previous literature – a huge variety of individuals who get crowded together in a single story.’ Within this scrum of characters, novels often rely on disease, illness, and caregiving to illustrate complex, multivalent social ties. As Miriam Bailin observes: ‘There is scarcely a Victorian fictional narrative without its ailing protagonist’; moreover, ‘multiple sufferers are the rule rather than the exception’. Tina Young Choi agrees, arguing that these novels emphasize illness because ‘disease revealed the ways in which the social enjoined participation, however involuntary’. Just as nineteenth-century public health experts tracked disease at both the national and local level, many novels also worked to envision the social ties that were exposed by – or even fostered in – the experience of illness. Yet illness in nineteenth-century novels is not merely an index of overwhelming social entanglements. Rather, fictional illnesses, injuries, and disabilities present opportunities to forge new, meaningful personal ties that could, theoretically at least, counterbalance the accumulation of anonymous social connections in the modern era. As Talia Schaffer observes, personal acts of care are a central motif of these texts: ‘Victorian novels constantly depict people forming ad-hoc, flexible, small groups of caregivers.’ Famous scenes of literary care include Jane’s recovery among her soon-to-be-discovered cousins in Jane Eyre and Joe’s gentle
Woloch, p. . Miriam Bailin, The Sickroom in Victorian Fiction: The Art of Being Ill (Cambridge: Cambridge University Press, ), p. . Tina Young Choi, Anonymous Connections: The Body and Narratives of the Social in Victorian Britain (Ann Arbor: University of Michigan Press, ), p. . Talia Schaffer, Communities of Care: The Social Ethics of Victorian Fiction (Princeton: Princeton University Press, ), p. .
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nursing of Pip in Great Expectations. These scenes of caregiving have sometimes been read as mere fantasies of social reconciliation for outcast characters. Yet more recently, scholars have begun to analyse how such caregiving plots are deliberate thought experiments that envision how health, like disease, is produced through interactions with others. According to the nineteenth-century British novel, then, both illness and its amelioration are, for better or worse, collective experiences. Time and again, novels of this era demand that readers envision ill-health as a shared condition: from the threat of contagions that spread across the planet, to philanthropic efforts to care for the poor, to the multigenerational home hushed by the illness of one member. Some visions of collectivity in these texts are intentionally disconcerting, like when contagious diseases reveal the permeable boundaries of individual bodies. Yet others are more beneficial, such as when one person’s caregiving needs bring together a diverse set of willing helpers. Novels do not always valorize the communal relations made apparent by illness, yet nevertheless, they insist upon illness as a shared challenge. This chapter will address this insistence on collectivity both as a sociomedical message and a formal literary aesthetic. Notably, in their size and scope, nineteenth-century novels differ greatly from today’s illness narratives, which largely focus on the interior life of an individual patient. Even in the field of narrative medicine, the goal is for clinicians to use storytelling to better understand the patient’s selfhood. As Rita Charon puts it, narrative medicine aims to cultivate ‘deep and accurate attention to the accounts of self that are told and heard in the contexts of healthcare’. Martha Montello complicates this claim by insisting on ‘a cluster of narratives’, though she still asserts that the task of narrative is to uncover ‘unique individuals, living within their own particular moral worlds’. Even when scholars critique narrative medicine, they tend to reconsider the notion of narrative, leaving intact the goal of representing the individual. Angela Woods, for example, points out the dangers inherent in assuming patients must express themselves in stories,
For readings of sickroom scenes as social reconciliation, see Bailin, pp. –. As Schaffer points out, such a vision of reciprocity links Victorian novels to modern care ethics, the philosophical school of thought that examines interdependencies among people. However, care ethics cannot be said to originate in Victorian sources, rather it has roots in several different cultural contexts, particularly among marginalized communities. See Schaffer, pp. –. Rita Charon, ‘Close Reading: The Signature Method of Narrative Medicine’, in The Principles and Practice of Narrative Medicine, ed. by Rita Charon and others (Oxford: Oxford University Press, ), pp. – (p. ). Martha Montello, ‘Narrative Ethics’, Hastings Center Report, (), S–S (pp. S, S).
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suggesting instead forms like metaphor, photography, and performance art as a means to ‘articulat[e] the experience of illness and its impact on the self’. This emphasis on the self stems from medical humanities’ desire to improve real-world clinical experiences for patients. Yet it may also reflect contemporary assumptions that illness, health, and recovery are primarily personal experiences, occurring solely within the bodies of individual sufferers. Though clinical work may continue to bend its focus towards the individual patient, the emergent field of critical medical humanities has an opportunity to trace the far-flung web of social ties that generates the personal experience of illness. This chapter, by foregrounding the shared imaginary of nineteenthcentury novels and medicine, offers an alternative scope for the illness experience and its narrative potential: not a story of the self alone, but a story of vast interconnections. Novels of this era chart social relationships on a wide range of scales: the global ties created through imperial exploitation, chance encounters between strangers in the street, years-long caregiving relationships among friends, as well as the close intimacy of narrators directly addressing the reader. In the twenty-first century, particularly in the aftermath of the COVID- pandemic, we desperately need narrative models that can not only value the patient’s perspective, but also situate individuals in larger webs of meaning and mutual influence. Nineteenth-century novels show us a path forward, as they embrace the bewildering task of representing the full range of diffuse and close-knit social ties that profoundly affect one’s health.
Public Health, Disease Maps, and the Multi-plot Novel The Victorians faced innumerable health threats, many of which appeared unique to the modern, industrialized era. Nineteenth-century Britain witnessed dozens of epidemics, including influenza, typhus, smallpox, typhoid, scarlet fever, and – perhaps most famous of all – cholera. Because of cholera’s association with imperial expansion, alongside its frighteningly sudden progression, it became ‘the signal disease of the
Angela Woods, ‘The Limits of Narrative: Provocations for the Medical Humanities’, Medical Humanities, , (), – (p. ). In this way, the study of Victorian novels can contribute to the conceptualization of COVID-era care ethics, offering a narrative template for the goal of ‘see[ing] ourselves as part of networks of need and dependence and to imagine ourselves as interdependent citizens’. Mercer Gary and Nancy Berlinger, ‘Interdependent Citizens: The Ethics of Care in Pandemic Recovery’, Hastings Center Report, , (), – (p. ).
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nineteenth century’. While endemic to India, cholera was unknown to European colonizers. Newly dense living situations, coupled with global transportation networks, allowed this endemic disease to break out into worldwide pandemics a total of six times in the nineteenth century. Yet along with contagious diseases, Victorians faced other dangers. Rapid urbanization created unprecedented sanitation problems. In impoverished, overcrowded neighbourhoods, overflowing waste pits caused raw sewage to seep through the walls of the poorest basement dwellings. During the infamous ‘Great Stink’ of , hot weather exacerbated the smell of sewage in the Thames so badly that it threatened to disrupt Parliament. Moreover, reformers were just beginning to perceive how industrialization caused chronic health conditions through lifelong exposure to tainted food, polluted environments, and long working hours. The human body appeared beset with dangers on all sides; thus medical experts imagined that identifying the specific causes of disease required a virtually omniscient knowledge of the human body within its environment. By the late nineteenth century, Robert Koch’s articulation of germ theory would greatly clarify the question of disease causation. However, before germ theory’s wide acceptance, reformers envisioned various models of illness that depended upon a network of external or environmental causes. One model, miasma theory, imagined that disease was produced by the emanations of rotting materials (such as the putrid smell of the Thames). Another, contagionism, hypothesized that a material transmission between people caused disease. While contagionism would prove nearer the mark, both these models seemed to require vast amounts of data to understand illness. Medical observers believed they needed to identify multiple contexts to comprehend disease: neighbourhood layouts, room ventilation, hygiene habits, dietary needs, work schedules, even climactic weather patterns. Yet such a wide purview for the causes of ill health also required new tools – statistics, maps, as well as new narrative techniques – in order to make manifest the ways that individual health was shaped by its surroundings.
Yet Hamlin notes that this is not solely because of the number of deaths but also ‘the magnitude of the reaction to it’. Christopher Hamlin, Cholera: The Biography (Oxford: Oxford University Press, ), p. . For accounts of the competing disease models of Victorian medicine, see Michael Worboys, Spreading Germs: Diseases, Theories, and Medical Practice in Britain, – (Cambridge: Cambridge University Press, ), and K. Codell Carter, The Rise of Causal Concepts of Disease: Case Histories (Aldershot: Ashgate, ).
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While we may dub our own era the ‘Information Age’, the nineteenth century also witnessed a proliferation of new data and new methods of analysis, particularly surrounding health statistics. As Ian Hacking notes, this century witnessed ‘an avalanche of printed numbers’ through which ‘nation-states classified, counted and tabulated their subjects anew’. Beyond the raw data of statistics, the emergent information literacy of this period can be traced to advances in print technologies. The cheapness and speed of lithographic printing, Tom Koch argues, ‘permitted the increased publication of charts, maps, and other graphics in texts’. Thus, public health experts, statisticians, and other reformers pioneered new ways of not only analysing data but also visualizing it. John Snow’s Broad Street map is a prime example of how medical statistics and print technology collaborated to capture a seemingly comprehensive rendering of public health. Tracking an cholera outbreak in London, Snow’s map overlays mortality rates directly on a neighbourhood, with each black bar representing a death at a specific street address. This method of disease mapping revealed that each case of the outbreak could be linked to the victim’s ingestion of water from the local Broad Street pump. This careful deduction demonstrated (though the theory was not widely accepted at the time) Snow’s contagionist belief that cholera was transmitted through contaminated water. Alongside Snow’s map, Florence Nightingale’s invention of the rose diagram remains iconic for its stark visualization of complex phenomena. Nightingale’s statistical assessment of the mortality rates at military hospitals in the Crimean War was largely ignored by the government, until she crafted vivid drawings of the data to show how drastically the mortality rates dropped off following her hygiene reforms. Through widely circulated statistical data, as well as such striking visualisations, Victorians were able to view their own health in novel ways. Medical writers urged their readers to situate themselves within a larger world where the goods they consumed, the streets where they lived, and the climates they inhabited all legibly shaped their health and well-being. Recent work in literary criticism has placed the nineteenth-century novel alongside contemporary maps, graphs, and statistical analysis as yet another tool for representing the social landscape. In fact, nineteenthcentury literary and medical writers borrowed from each other’s
Ian Hacking, The Taming of Chance (Cambridge: Cambridge University Press, ), p. . Tom Koch, Disease Maps: Epidemics on the Ground (Chicago: University of Chicago Press, ), p. . Lee Brasseur, ‘Florence Nightingale’s Visual Rhetoric in the Rose Diagrams’, Technical Communication Quarterly, , (), – (p. ).
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representational strategies. Novels drew from the public health imaginary by using the narrative strategies of medical case histories and by plotting medically accurate scenes of disease transmission. Conversely, as Maeve E. Adams discovers, statistical reports mirrored contemporary novels. These reports ‘often contained a feature now regarded as a hallmark of the social realist novel: the use of an individual character or scene, by which the writer could move from the social aggregate, understood and imagined as a whole, to the more intimate details of the lives of those who made up the aggregate’. Indeed, some statistical reports even cited contemporary novels as evidence of actual working-class life. Similarly, Anjuli Fatima Raza Kolb argues that we can read nineteenth-century epidemiology as a ‘paraliterary genre’ that uses narrative and close reading to make data meaningful. Thus, far from delineating the literary from the medical, Tina Young Choi posits that we can discuss a cohesive sense of ‘the emerging technologies of the age, from statistics to urban fiction, [which] provided the tools for describing more complex relationships between one body and another’. Novels and medical statistics shared the task of making complex, diffuse systems imaginable for a public audience. Just as the black bars on John Snow’s map represent complex local dynamics, novels like Charles Dickens’s Bleak House (–) render visible a sliver of the vast social ties forged in a rapidly expanding city like London. While earlier novels often centred on a few elite or middle-class characters, Bleak House represents a Victorian trend towards many more characters from more economic classes. These characters are united in the multi-plot novel through widely disparate links, including family ties, legal cases, employee/employer relationships, communicable diseases, even simple physical proximity on the street. The novel opens with an omniscient narrator’s elevated, map-like view of the city, which can even pierce through an all-obscuring mist. The narrator observes: ‘Fog everywhere. Fog up the river, where it flows among green aits and meadows; fog down
See Meegan Kennedy, Revising the Clinic: Vision and Representation in Victorian Medical Narrative and the Novel (Columbus: Ohio State University Press, ), pp. –. Maeve E. Adams, ‘Numbers and Narratives: Epistemologies of Aggregation in British Statistics and Social Realism, c. –’, in Statistics and the Public Sphere: Numbers and the People in Modern Britain c. –, ed. by Tom Crook and Glen O’Hara (New York: Routledge, ), pp. – (p. ). Adams, p. . Anjuli Fatima Raza Kolb, Epidemic Empire: Colonialism, Contagion, and Terror, – (Chicago: University of Chicago Press, ), p. . Choi, p. .
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the river, where it rolls defiled among the tiers of shopping, and the waterside pollutions of a great (and dirty) city’. This opening, which goes on to trace the pestilential fog across the entire urban landscape, sets the stage for the distinctive scale of this novel. Bleak House runs to nearly a thousand pages in many editions, has over fifty characters, as well as two separate narrators (the past-tense voice of Esther Summerson, alongside the grandiose, present-tense omniscient narrator). In its very heft and duration, Bleak House aims to offer a small sample of the unfathomable interactions that characterize modern urban living. Within this wide vision, Bleak House alights on themes of illness, disease, and injury as powerful means of tracking social relationships. While initially strangers, Jo, Charlie, and Esther end up passing along a contagious fever (generally taken to be smallpox), after Esther’s charitable efforts bring them together. In one reading, such shared vulnerability is a threat to the respectability of the middle and upper class. When Esther succumbs to the disease, her fever dreams reflect a dread of uncomfortably close social ties. She hallucinates ‘a flaming necklace, or ring, or starry circle of some kind, of which I was one of the beads! . . . my only prayer was to be taken off from the rest’. As Pamela Gilbert argues, this scene shows ‘Dickens’s principal theme – the social connectedness of all the characters in the novel’. But while Gilbert argues that the novel ultimately aims to minimize the ‘painfully fluid’ relationships among individuals, another possibility is that the novel embraces the inescapable peril of contagious illness as an actionable social tie. Elsewhere, Bleak House laments the untenable conditions of urban slums, where human waste overflows into the streets and ramshackle dwellings often collapse. To demand social reform, Dickens’s fiery omniscient narrator points out the risk the slums pose to the aristocratic rich, who may have never entered such places but are still vulnerable to the diseases fomented there. Notably, medical care was available to impoverished Londoners through various major hospitals, yet Dickens’s narrator insists that the rich have used such medical charity as a justification for complacency towards the root causes of disease. Thus, he brandishes the threat of communicable disease as an
Charles Dickens, Bleak House, ed. by Nicola Bradbury (New York: Penguin, ), p. . For a full reading of the form of this novel, see Caroline Levine, Forms: Whole, Rhythm, Hierarchy, Network (Princeton: Princeton University Press, ). Dickens, p. . Pamela Gilbert, The Citizen’s Body: Desire, Health, and the Social in Victorian England (Columbus: Ohio State University Press, ), p. . Gilbert, p. .
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urgent call to more comprehensive action. Personifying the slum, the narrator warns: ‘There is not an atom of Tom’s slime, not a cubic inch of any pestilential gas in which he lives not one obscenity or degradation about him . . . but shall work its retribution, through every order of society, up to the proudest of the proud.’ Thus the social connections that are made manifest in transmissible diseases are both overwhelming in their enormity, and potentially unifying in directing widely divergent populations towards shared goals. While not every disease outbreak could be traced with the precision of John Snow’s cholera map, novelistic narrative strategies allowed writers, both literary and medical, to reveal the ways that readers’ bodies were implicated within larger social systems. Choi describes how contagionists used multi-plot narrative forms, as these formal structures could ‘render visible the moment of communication between individuals that would otherwise go unmarked’, thus making contagionism conceivable to a pregerm theory audience. Yet more than this, I argue, such novelistic forms helped to transform conceptions of ill health from a personal experience to a widely shared plight within the larger imaginary of nineteenth-century Britain. Given the ways that shared water, air, and streets inevitably linked diverse individuals, the health of the one was predicated on the health of the many.
Caregiving, Health, and Novelistic Endings In the Victorian imaginary, then, the individual body was becoming hopelessly entangled with innumerable other bodies as well as various unhealthy environments. Illness could be traced to such various sources as: ventilation of the room in which one slept, the hygiene of one’s neighbour, the conditions of one’s work, the cleaning methods of a laundress, the infrastructure of one’s city, or the passing touch of a nameless international traveller. In our own pandemic experience, with our sanitized surfaces, masking protocols, contact tracing, and border controls, it is easy to visualize the scale of dangers Victorians identified in their surroundings. Yet what remains unfamiliar, perhaps, is Victorian
Dickens, p. . Choi, p. . For the purposes of this essay, I am focused on the beneficial public health outcomes of such a collectivist paradigm. However, later in the century, Victorians’ ideas of collective health also led to programmes of surveillance and even incarceration of individuals who were considered threats to social health, including prostitutes accused of spreading venereal disease and people suffering mental illness.
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reformers’ vision of how to ameliorate the systemic ill health exposed through specific disease outbreaks. As nineteenth-century physicians and public health experts aimed to locate the sources of illness, their attention was focused on not only the aetiology of specific diseases, but also systemic issues of city sanitation, food insecurity, and working conditions. Indeed, they even factored in more mundane stressors like overwork, emotional distress, and the lack of meaningful relationships. In such a wide purview of the causes of ill health, one thing became quite clear: illness was not the only condition produced through a vast array of systemic causes. Health too was the outcome of multiple, overlapping networks of support, ranging from personal friendships to healthy environments to humane working conditions. Because of this insight, Victorian reformers – including many physicians – increasingly viewed medicine as just one aspect of a holistic response to systemic ill health. While medicine could focus on treating disease within individual bodies, other means were necessary for promoting robust health across society. In this vein, novels of the era often position themselves as a critical supplement to other kinds of knowledgemaking about the body. Novels could teach readers not only to see the branching effects of disease, but also to track how health was produced through complex, recursive networks of care. Historians have often described the growing authority of empirically grounded, or what became called ‘scientific’, medicine in the nineteenth century; however, many physicians and other advocates in this period viewed even effective medical treatment as insufficient to grapple with the health problems evident in urban, industrialized societies. For example, writing in , Dr John Roberton called attention to the untenable situation of impoverished patients whose recoveries were foiled by the burden of work, unhealthy homes, and meagre food. ‘They are the ignorant only’, he surmised, ‘who appeal under all circumstances to the laboratory’. Instead, Roberton argued for the necessity of rest, nutrition, and an extended reprieve from work as key factors in the treatment of prolonged illness. Similarly, Nightingale decried hospitals that focused solely on their cutting-edge medical and surgical treatments, ignoring a more comprehensive view of their caregiving practices, architectural design, and overall mortality statistics. Writing from the perspective of a nurse who sees the day-to-day suffering of patients, she noted: ‘One
John Roberton, ‘Suggestions for Establishing Convalescents’ Retreats on the Sea Coast, as Subservient to the Hospitals and other Medical Charities of Large Towns’, Edinburgh Medical and Surgical Journal, , (September ), – (p. ).
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insensibly allies together restlessness, languor, feverishness, and general malaise, with closeness of wards, defective ventilation, defective structure, bad architectural and administrative arrangements’. Given such factors as contaminated air, overcrowded wards, and emotionally depressing surroundings, she mused, ‘it is impossible to resist the conviction that the sick are suffering from something quite other than the disease inscribed on their bed-ticket’. Even effective treatments of disease, according to many nineteenth-century thinkers, needed to be paired with other supports in order to foster health. Notably, both these thinkers put their critiques into practice: Roberton championed the development of convalescent homes for post-acute patients and Nightingale pioneered new architectural designs for hospitals to encourage better interpersonal care. Some reformers even looked beyond the individual medical patient to address ill health. The highly influential Charity Organization Society (COS) suggested that a focus on merely the medical patient was too narrow. As the COS reasoned in one report: ‘Behind the distress of these evident sufferers is a large amount of hidden misery which is also a part of the “case”. The rest of the family at home – what of them? The patient recovered . . . – what of his or her prospects of a livelihood in the future?’ The COS proposed interventions for whole family units, suggesting that medicine’s traditional understanding of a ‘case’ failed to ‘really comprehend the whole malady’. Most ambitiously, the COS asserted, only a holistic look at an entire household ‘would represent a cure in its perfection, from an all-round point of view’. Many nineteenth-century novels took a similarly comprehensive view of illness and its amelioration. Yet novels also expanded beyond the COS’s paradigm of the nuclear family to imagine whole communities affected – and even created – by the experience of illness. One may think of the famous illness plots in Jane Austen’s novels: in Sense and Sensibility Marianne’s illness solicits the care of even casual acquaintances and in Emma Mr Woodhouse’s bodily needs require the newlywed couple to share his home at the conclusion. Further into the nineteenth century, the scenes surrounding illness generate even larger social networks. In Elizabeth Gaskell’s Mary Barton, a vivid scene of one man’s illness
Florence Nightingale, Notes on Hospitals, rd edn (London: Longman, ), p. . Nightingale, p. . Charity Organization Society, Charities Register and Digest: Convalescent Homes, nd edn (London: Spottiswoode, ), London Metropolitan Archives, Family Welfare Association Collection, A/ FWA/C/H/, p. . Charity Organization Society, p. . Charity Organization Society, p. .
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comes to represent the ways that sickness has ripple effects, and the amelioration of ill health must be similarly large-scale. Two working-class men, Wilson and Barton, visit the house of an ill acquaintance, Davenport, and find the whole household in dire straits. The men hasten to intervene. In addition to attending to the ill man, they buy food, light a fire, care for the children, and even spoon-feed Mrs Davenport, who is ‘well-nigh clemmed’ and ‘past hunger’. In this scene, an entire family suffers because of the illness of its breadwinner, yet the caregiving community produced in response to such suffering is even more capacious, extending beyond the nuclear family and even scrambling conventional gender roles as the men act as ‘rough, tender nurses’ to an adult woman in need. Notably, however, the attentive care of Wilson and Barton, who are poor and out of work like Davenport himself, is put in stark contrast with the lack of care displayed by their upper-class employers. Leaving the scene of the Davenports’s suffering, Barton walks to ask for the assistance of Mr Carson, the factory owner. This short walk through Manchester takes Barton to a totally new world. He enters an affluent home, where the servants are well-fed and he finds his former employer reading for leisure ‘in the luxurious library, at the well-spread breakfast-table’. While Bleak House imagines that contagious disease can serve as a crucial conduit for sympathy across classes, here the insulation of the upper class is almost insurmountable. Carson offers a ticket for out-patient medical care, but it is clear that individual-centred medical treatment is insufficient to solve Davenport’s compounded plights of illness, unemployment, malnutrition, and familial suffering. Carson fails to recognize his responsibility towards his former employee – he does not even recognize Davenport’s name – and more fundamentally misunderstands the scope of intervention needed in this case. In describing this tragic misreading, Gaskell highlights a significant role for the novelistic form. In this text, the forced proximity of modern living fails to produce positive, actionable social relationships across the social classes. Recounting John Barton’s walk through Manchester, Gaskell’s narrator exclaims, ‘he could not, you cannot, read the lot of those who daily pass you by in the street’. Yet the anonymity of city-living is no
Elizabeth Gaskell, Mary Barton, ed. by Macdonald Daly (London: Penguin, ), p. . Gaskell, p. . See Schaffer for a larger account of how caregiving communities often transcend gender norms (pp. –). Gaskell, p. . Gaskell, p. .
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excuse. As Barton complains earlier, the affluent should not simply plead ignorance of the plight of the poor: ‘I say, if they don’t know, they ought to know’. While the city itself cannot train people to cultivate beneficial social ties, according to Gaskell, the novelistic form can. In the scene above, Gaskell calls out the reader, placing ‘you’ alongside Barton as someone who cannot ‘read’ the full humanity of others passing in the street. Yet that carefully chosen verb ‘read’ also hints at the solution. As a reader of this novel, one gains the access that one may lack in the real world. When Barton and Wilson first arrive at the Davenport home, ‘you’ are there also: ‘You went down one step even from the foul area into the cellar in which a family of human beings lived. It was very dark inside.’ Through such rhetorical moves, the novel expands the caregiving network to include the reader, who not only sympathizes emotionally but also witnesses the pragmatic interventions needed in such a situation. Thus, the act of reading a novel can inform readers of their place not only in the network of disease but also their role in its amelioration. As we have seen, Victorian novels, alongside contemporary medical and public health experts, are deeply invested in grappling with the scale of ill health in the modern world. Novelistic narrative strategies insist upon situating the individual within a sprawling network of influences that, while focused on a single urban location, often extend off into the horizon to hint at the entire globe. Some scholars have argued that nineteenthcentury novels advocate for the closure of the body against outside influences. Indeed, with the wider acceptance of germ theory at the end of the century, we can see a shift in the English language itself from depicting germs as seeds of disease to envisioning germs as an invasion to be repelled. However, for many Victorian thinkers, removing oneself from the influences of other bodies was no solution, even if it were possible. Rather, the goal was to activate a newfound awareness of one’s social embeddedness to forge positive relational ties, which in turn could foster health in the midst of incalculable risks and dangers. For many novels, then, wrapping up the plot requires locating appropriately small-scale networks in which positive social ties can be as palpable as large-scale threats to health. Notably, many scholars have derided novelistic endings that usher main characters out of urban cities to rural locations, seeing such movements as regressive retreats into idealized settings. In Bleak House, Esther Summerson and her husband decamp from the seemingly irredeemable London to Yorkshire. In Mary Barton,
Gaskell, p. .
Gaskell, p. .
Gilbert, pp. –.
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Worboys, pp. –.
the protagonists leave England entirely to emigrate to Canada. Perhaps the most notoriously small-scale novelistic resolution occurs in George Eliot’s Middlemarch, where Dorothea Brooks’s early promise to live an epic life concludes with her ‘unhistoric’ good works: ‘Her full nature . . . spent itself in channels which had no great name on the earth’. Certainly, these endings often convey a deep pessimism for the current state of urban life. Moreover, they often seem to relegate female protagonists to stereotypical domestic roles. Esther, Mary, and even Dorothea are primarily defined by their caregiving, both for their families and their local communities. Nevertheless, I suggest that scholars miss the ways that these novels replace simplistic ideals of closure with ongoing systems of support, care, and reciprocity. Certainly, looking solely at the protagonist’s fate, homely endings within small communities may seem like a let-down. Yet, as I have already discussed, novels of this era are not exclusively interested in the mere individuality of the protagonist. While the central characters of these stories often conclude with small spheres of influence, this local scope is not automatically a failure. Rather, these endings acknowledge that all of us – no matter our grand aspirations or influence – still exist in a particular place. We are each already in relationships with neighbours, family members, employers, co-workers, local authorities, and the natural world. For these novels, health rises out of the proper functioning of these mundane relationships. In these endings, the protagonist’s personal aspirations fade away in favour of a social network where the effects of modern ill health can be counteracted by sustained acts of care among people who share a time and place. These small communities can then serve as paradigms to envision ways to chip away at the larger, ineffable systems that threaten to occlude such local supports and responsibilities. Notably, of course, caregiving communities in Victorian novels fail as often as they succeed. Yet the key point is that human health – both its dangers and its supports – exists in context. Thus, as Schaffer notes, it is a mistake to delineate a hard line between health and illness, or even disability and ability: ‘Enmeshed as we are in networks of obligation, gratitude, and assistance, we need to recognize our own profound social ties. None of us are autonomous; our very selfhood is intermeshed with others’. This understanding of the self was intuitive for many nineteenth-century thinkers. William Farr, a renowned physician,
George Eliot, Middlemarch, ed. by David Carroll (Oxford: Oxford University Press, ), p. . Schaffer, pp. –. Schaffer, p. .
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Illness and the Novel Aesthetics
statistician, and public health reformer, argued for many levels of social intervention for illness. In a speech advocating for disparate initiatives like mutual aid funds, paid life insurance, and governmental Poor Laws, Farr observed that any model of health or economic stability that relied solely on individual striving was misguided. One need only look to statistics, he reasoned, to recognize that every year ‘a certain number of persons are unequal to this labour; [and] none are equal to it at all periods of life and in all circumstances’. Given the utter normalcy of periods of need, then, illness could not be seen as an aberration, nor as a purely personal affliction. Victorian novels insist upon showing how health and illness emerge from networks which expand well beyond the individual patient, as well as their healthcare provider.
Conclusion: Novelistic Subjectivity in a Pandemic Era Since at least Georg Lukács’s Theory of the Novel, critics have argued that novels cultivate readers’ subjectivity. Characters like Clarissa Harlowe, Elizabeth Bennet, and David Copperfield become fully imagined people in our minds, then teach us to develop a similarly complex inner life. My aim here has been to modify this assessment slightly. The subjectivity of the Victorian novel is always already implicated in a larger world. This, then, is the selfhood that these novels cultivate: the self that is one of many, one in a crowd, one of a community, one in a web of responsibilities. In this focus, nineteenth-century novels have much to say to modern medical humanities. As Des Fitzgerald and Felicity Callard insist, critical medical humanities must move beyond a default focus on the individual patient: ‘we need to displace, if not significantly reimagine, how medical humanities has tended to figure the “human” – an entity whose boundaries have commonly been understood to end at her skin’. Indeed, in the aftermath of the COVID- pandemic, the medical encounter itself is too narrow a scope in which to envision even a single patient’s story. One recent study of long-COVID sufferers observed that much of the interpolation of this condition happens outside of the clinical setting: ‘Instead of sharing their narratives in therapeutic dialogue with their own clinician, people struggled with a fragmented inner monologue before finding an
Willian Farr, ‘On Benevolent Funds and Life Assurance in Health and Sickness’, The Lancet, , (), – (p. ). Des Fitzgerald and Felicity Callard, ‘Entangling the Medical Humanities’, in The Edinburgh Companion to The Critical Medical Humanities, ed. by Anne Whitehead and Angela Woods (Edinburgh: Edinburgh University Press, ), pp. – (p. ).
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empathetic audience and other resonant narratives in the online community’. Perhaps, then, this emerging condition demands the kind of society-wide narration strategies modelled by Victorian novels. As the researchers elaborate: ‘Individually, the stories seemed to make little sense. Collectively, they provided a rich description of the diverse manifestations of a grave new illness, a shared account of rejection by the healthcare system, and a powerful call for action to fix the broken story’. Thus, like in the Victorian novel, here the personal experience of illness is enmeshed in the experiences of other sufferers, in the invisible spread of disease across dizzying scales of population, and in the pragmatic efforts of others to identify and attend to need. Only in reconnecting the individual sufferer to larger systems – often through narrative – can the illness experience itself be understood. The COVID- pandemic has forced many of us to situate ourselves among countless others: the healthcare providers, custodians, caregivers, grocery workers, commuters, even the anonymous online commenters, whose health is tied up with our own. At this moment in history, we know all too well the ways that our own bodies are implicated in global travel networks, systemic inequalities, chance encounters, and personal acts of caregiving. Nineteenth-century novels offer a model, or at least a precedent, for grappling with such various scales of the social through narrative.
Alex Rushforth and others, ‘Long Covid – The Illness Narratives’, Social Science & Medicine, (), – (p. ). Rushforth, p. .
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Embodied Traumas in Twentieth- and Twenty-First-Century Literature Alan Gibbs
For several years in the late twentieth and early twenty-first centuries, trauma became a leading theoretical paradigm in Western literary culture. This dominance is undoubtedly attributable to a broad range of sociocultural determinants, but three key events might be identified as especially crucial. First, in , the insertion of post-traumatic stress disorder (PTSD) into the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III); second, the publication of Cathy Caruth’s edited collection Trauma: Explorations in Memory () and her monograph, Unclaimed Experience: Trauma, Narrative, and History (); and third, the attacks on the Pentagon and the World Trade Center on September . During this period, PTSD became a term familiar even in popular culture, while both personal and collective events and cultural phenomena were increasingly interpreted through the lens of trauma. As in most studies of the phenomenon, trauma is understood in the following to reflect both the causal events and the reaction of those who experienced them. Embodiment in this sense is pertinent to both cause and reaction. That is, traumatic events frequently take the form of unexpected violations of the human body, while the response to traumatic stimuli, although varying significantly among sufferers, is located in traces left in the body, including the individual’s psyche. In order to encompass this notion that trauma manifests through a range of psychological and physical effects, the definition of ‘embodied trauma’ in the following chapter is deliberately broad. In the case of trauma and trauma theory, medical and literary practices are heavily imbricated. The increasing cultural pervasiveness of trauma in the West has influenced literary production, but literature has also affected how trauma is understood, especially through the range of representational practices writers have adopted. This chapter first examines the development of trauma, especially as a cultural theory, and its relationship with
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associated literature and criticism. A second section considers a selection of trauma texts from the mid-twentieth century onwards, with a particular focus on Toni Morrison’s novel, Home (). Home offers some particularly useful illustrations of the ways in which trauma representation has become both less aesthetically programmatic and broader in focus, especially in terms of taking into account trauma’s social origins. This latter element is also reflected in the short subsequent discussion of a selection of twenty-first-century texts – including Cormac McCarthy’s The Road and Rumaan Alam’s Leave the World Behind – which allude to wider traumatic changes facing humanity. Contemporary writers, as we shall see, are thus drawing on and developing ideas and forms associated with trauma to respond to broad urgent issues, including climate catastrophe.
The Trauma Paradigm Trauma as a – largely Western – concept emerged in nascent form during the late nineteenth century, reflecting the incidence of injuries resulting from industrialization during that period. A discourse around ‘railway spine’ developed, when for the first time there was a recognition that physically affecting events could have psychological consequences. It was also during this period that the meaning of trauma began to change, so that the term encompassed not only physical wounds – its original meaning – but also psychological effects. As I have already suggested, this conceptual imbrication in trauma between the bodily and the psychological persists to this day. By this time a primarily psychological concept, trauma began to become more thoroughly defined in the age of modernity, through the writings of those in the emerging discipline of psychoanalysis, such as Pierre Janet and Sigmund Freud (in particular the latter’s ‘Remembering, Repeating and Working Through’ and Beyond the Pleasure Principle). The notion of psychological damage gained further acceptance as a result of ‘shell-shocked’ soldiers returning from the First World War. It is beyond the scope of this chapter to provide a full genealogy of trauma, and so the focus of discussion in this initial section is instead on the increasing dominance of the concept in Western discourse from the s onwards.
See Roger Luckhurst, The Trauma Question (London: Routledge, ), pp. –. Ruth Leys, Trauma: A Genealogy (Chicago: University of Chicago Press, ), and Luckhurst both include detailed delineations of the origins and development of the concept.
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Embodied Traumas in Literature
As mentioned above, the coining of PTSD and Caruth’s initial writings are key to this development, alongside the attacks of /, which were predominantly interpreted in terms of collective trauma. Dominant concepts in the field, PTSD and Caruthian cultural trauma theory are by no means mutually exclusive, but they do have contrasting origins. A line may be traced from shellshock to PTSD, one which would most certainly pass through the experiences of American soldiers in Vietnam. As discussed later in the chapter, concerted lobbying by Vietnam veterans’ groups was instrumental in the official recognition of PTSD, and so although the concept widened after its initial coining in DSM-III, its origins reside in combat trauma. Caruth’s trauma theory, by contrast, comprises a peculiar admixture of the writings of Freud, theories derived from Holocaust Studies, and the post-structuralism of Paul de Man. These complex origins mean that PTSD and Caruthian theory are characterized by certain jarring incompatibilities, both with each other and internally. For example, where PTSD emerged from the experience of agents who may be identified as perpetrators, Caruthian theory, with contrasting origins in Holocaust Studies, shuns any such focus. Partly because of these origins, Caruth’s trauma theory includes a moral imperative that is entirely absent from PTSD, one which draws a distinction between the experiences of the ‘victim’ and the ‘perpetrator’, and prohibits focus on the latter. I shall examine Caruth’s theories in more detail shortly, but first it is necessary to consider the clinical model of trauma, PTSD, which has heavily influenced cultural trauma theory. The role of the Vietnam veterans’ lobbying groups alongside anti-war psychiatrists in the ratification of PTSD raises the difficult question of whether it is a diagnosed medical condition or a sociopolitical construct. This is an important issue not least because if PTSD is, as Allan Young and others have argued, a construct, stitching together various conditions and symptoms into a collective syndrome, then PTSD diagnoses perpetuate the concept and reinforce its
For a discussion of / and the uses to which the concept of collective trauma was put, see the third chapter of Alan Gibbs, Contemporary American Trauma Narratives (Edinburgh: Edinburgh University Press, ). Cultural trauma theory, being in part founded on Caruth’s reading of Torquato Tasso’s epic poem, La Gerusalemme Liberata, includes some awkward unconscious acknowledgement of the perpetrator’s experience at its heart. Caruth notoriously interprets Tasso’s protagonist Tancred as a victim, whereas a number of commentators have argued he is more convincingly understood as a perpetrator. For a more detailed discussion of the implications of Caruth’s reading of Tasso, and its origins in Freud, see Sigrid Weigel, ‘The Symptomatology of a Universalised Concept of Trauma: On the Failing of Freud’s Reading of Tasso in the Trauma of History’, trans. by Georgina Paul, New German Critique, (), –.
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defining power. Nevertheless, PTSD gained huge traction as a clinical diagnostic tool, and whether understood as medical or sociopolitical, it came to dominate the way in which trauma was understood in the West. Key symptoms – including flashbacks, hyperarousal, and constriction – became culturally pervasive ways of understanding PTSD, indeed rapidly becoming clichés in the representation of trauma in literature and visual media. A key problem with this cultural and clinical pervasiveness is that PTSD becomes an increasingly monolithic method of conceiving traumatic experience. As Emma Miller observes, ‘while the professional recognition of PTSD in the s by the medical community helpfully legitimated the symptoms of traumatic experience, many have since queried whether it is wise to use one term to describe individuals who have had such disparate traumatic experiences that may lead to such distinct outcomes’. Not only monolithic, PTSD is also very Western-centric, excluding manifestations of trauma from other cultures. Ethan Watters describes how American psychological models, including PTSD and its treatments, have been exported from the US across the world with a near missionary zeal. A chapter in Watters’s book, Crazy Like Us, describes Western aid agencies’ responses to the Sri Lankan tsunami as ‘likely the largest international psychological intervention of all time’. Watters notes that the West’s rush to provide psychological counselling to victims of the tsunami gave little thought to ‘whether PTSD was a diagnosis that could be applied in all human cultures’. As a result, an army of Western therapists, with their culturally imperialistic focus on individual pathology, unwittingly trampled over local attempts to deal with the tsunami’s aftermath. ‘Because the Western conception of PTSD assumes the problem . . . is primarily in the mind of the individual,’ Watters observes, it marginalizes ‘the most salient symptoms for a Sri Lankan, those that exist not in the psychological but in the social realm.’ Western insistence on treating psychological hurt according to the perspective afforded by PTSD thus is not only ineffective, but ‘may actually exacerbate the problem’. Clearly, trauma is embodied in strikingly contrasting ways across different cultures, and not necessarily how PTSD stipulates. As we shall see, the
See Allan Young, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder (Princeton: Princeton University Press, ). Emma V. Miller, ‘Trauma and Sexual Violence’, in Trauma and Literature, ed. by Roger J. Kurtz (Cambridge: Cambridge University Press, ), pp. – (p. ). Ethan Watters, Crazy Like Us (New York: Free Press, ), p. . Watters, p. . Watters, p. . Watters, p. .
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critique of PTSD’s Western bias informs arguments not only in the clinical sphere, but also the cultural. Caruth’s strand of cultural theory operates according to three principal symptoms of trauma: belatedness, literality, and punctuality. Belatedness, a characteristic Caruth incorporates through the Freudian concept of Nachträglichkeit, stipulates that trauma is always structured by delay. Caruth insists that trauma is so sudden and intrusive that it overwhelms the subject’s capacity to assimilate the event to conscious memory, and so the trauma sufferer experiences a period of – potentially permanent – amnesia regarding the event. According to this model, the traumatic event returns to the sufferer during the period of Nachträglichkeit in the form of incomplete and involuntary flashbacks and nightmares. Belatedness accompanied by flashbacks, and the associated notion of the repressed memory, subsequently gained widespread cultural recognition. A number of theorists have more recently cast doubt on the necessarily belated character of trauma, and suggested instead that trauma is usually manifested as an all too conscious haunting of the subject. The belatedness model also entails a conception of traumatic memory as being categorically different to regular memory processes, a distinction which, as Richard McNally has observed, has not been consistently demonstrated in neuroscientific research. More recently, Joshua Pederson cites research which suggests that some trauma sufferers experience dissociation and therefore belatedness, whereas others do not, with traumatic memories remaining conscious. The key point here is that in insisting on belatedness as a characteristic, Caruth’s cultural trauma model is monolithic and exclusionary. Caruthian theory also maintains that if and when traumatic memories do return, either as flashbacks or nightmares, or recovered into conscious memory, they do so as a precise recreation of the traumatic event. Caruth argues that in this sense, ‘ the flashback or traumatic event conveys, that is, both the truth of an event, and the truth of its incomprehensibility’. As with
Nachträglichkeit, generally literally translated as ‘afterwardsness’, derives initially from Freud’s work, but its provenance in late-twentieth-century trauma discourse owes a significant debt to Caruth’s writing. Richard J. McNally, ‘Conceptual Problems with the DSM-IV Criteria for Posttraumatic Stress Disorder’, in Posttraumatic Stress Disorder: Issues and Controversies, ed. by Gerald M. Rosen (Chichester: John Wiley and Sons, ) pp. – (p. ). Joshua Pederson, ‘Cognitive Approaches to Trauma and Literature’, in The Routledge Companion to Literature and Trauma, ed. by Colin Davis and Hanna Meretoja (London: Routledge, ) pp. – (p. ). Trauma: Explorations in Memory, ed. by Cathy Caruth (Baltimore: Johns Hopkins University Press, ), p. , original italics.
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belatedness, this facet emphasizes the unique character of traumatic memory, which for Caruth is imprinted directly onto the unconscious rather than assimilated into conscious memory. Caruth based these claims largely on the neurological research of Bessel van der Kolk. More recently, however, the methodology of this research on Vietnam veterans has been strongly challenged. As McNally points out, van der Kolk ‘simply asked . . . PTSD patients . . . whether their nightmares matched the combat events the patients had experienced in Vietnam’, with predictable results. The notion that a flashback or nightmare can ‘literally replay the sensory aspects of the traumatic experience’ is thus misleading, given that ‘the standard against which the dream is compared – the trauma as recalled by the dreamer when awake – is itself a fallible reconstruction of the event’. Finally, Caruth’s model contends that trauma is necessarily the result of a sudden, overwhelming event that is ‘experienced too soon, too unexpectedly, to be fully known and is therefore not available to consciousness until it imposes itself again, repeatedly, in the nightmares and repetitive actions of the survivor’. For Caruth, this explains trauma’s belatedness: the sudden character of the incident is too overwhelming to be assimilated to consciousness, and the event is therefore unavailable in memory. Given Caruth’s theories’ origins in Holocaust Studies, it is anomalous that trauma is characterized as the result of a single overwhelming event. It is similarly surprising that Caruth’s own edited collection includes Laura Brown’s essay ‘Not Outside the Range’, which disputes the notion that trauma is always the result of a single event. Trauma is clearly often produced by longer-term conditions such as poverty, malnutrition, suffering continual sexual abuse, or living under oppressive political regimes. Brown’s experience as a psychotherapist meant that she encountered numerous female trauma sufferers whose traumas were not, as DSMIII insists, ‘outside the range of human experience’, but instead, as she puts it, a ‘picture of “normal” traumatic events’. In other words, Brown discovered that many American women’s experiences comprised repeated abusive and traumatic situations as part of their quotidian life. Pressure
See the chapter by Bessel van der Kolk and Onno van der Hart in Caruth’s edited collection, Trauma: Explorations in Memory, pp. –. McNally, p. . See also Gibbs, pp. –, for further discussion of this issue. Cathy Caruth, Unclaimed Experience: Trauma, Narrative, and History (Baltimore: Johns Hopkins University Press, ), p. . Laura S. Brown, ‘Not Outside the Range: One Feminist Perspective on Psychic Trauma’, in Trauma: Explorations in Memory, ed. by Caruth, pp. – (p. ).
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Embodied Traumas in Literature
from feminist critics such as Brown and Judith Herman helped at least to revise the definition of PTSD, which from the fourth edition of the DSM in removed the criterion of ‘outside the range of normal human experience’ to acknowledge that everyday abuse could be traumatizing. This punctual character of the dominant trauma models has also been a particular target of postcolonial critics. The introductory article of a issue of Studies in the Novel on representations of trauma, by coeditors Stef Craps and Gert Buelens, constructs an explicit link between postcolonial and insidious trauma: ‘[r]outinely ignored or dismissed in trauma research, the chronic psychic suffering produced by the structural violence of racial, gender, sexual, class, and other inequities has yet to be fully accounted for’. More recently, Michael Rothberg has pointed out how incidents such as factory fires in the Far East demonstrate that ‘an event-focused trauma theory needs to understand the conditions of structural violence’. Craps and Rothberg have written extensively on this issue, observing that theory needs to be much more attuned to structurally insidious traumas in the developing world in order not to be complicit with the political inequalities that produce them. As Craps points out, this gestures towards a broader problem with dominant trauma models, which tend to pathologize or medicalize problems at the level of the individual psyche, a strategy that ‘tends to leave unquestioned the conditions that enabled the traumatic abuse, such as racism, economic domination, or political oppression’. Trauma diagnoses mean that political or economic issues are medicalized and thereby normalized, while victims are pathologized at the expense of meaningful social change. There are clearly numerous important objections which have been levelled at the dominant trauma models in terms of the effects of their diagnostic power. It is important now to turn to the impact of these dominant models of trauma on the literary representation of the condition. As already suggested, this is a two-way process, whereby theoretical trauma models have heavily informed literary representations, while the latter have also influenced the way in which trauma is understood culturally, and therefore folded back into the clinical arena.
Stef Craps and Gert Buelens, ‘Introduction: Postcolonial Trauma Novels’, Studies in the Novel, , – (), – (pp. –). Michael Rothberg, ‘Preface: Beyond Tancred and Clorinda: Trauma Studies for Implicated Subjects’, in The Future of Trauma Theory, ed. by Gert Buelens, Sam Durrant, and Robert Eaglestone (London: Routledge, ), pp. xi–xviii (pp. xiv–xv). Stef Craps, ‘Beyond Eurocentrism: Trauma Theory in the Global Age’, in The Future of Trauma Theory, ed. by Buelens and others, pp. – (p. ).
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One way of understanding the emergence of particular conventions in the representation of trauma would note the appearance in Western literature – certainly following the Second World War and the Holocaust – of a greater number of what might be classed as trauma texts. Published in increasing numbers, these works begin to form a genre with certain shared formal conventions, broadly deriving from literary modernism and postmodernism. Modernist repetition, or non-linear fragmentation of narrative, for example, is subsequently augmented by postmodernist anti-realism and metafictional conceits. As the genre grows in quantity and prominence, a body of criticism notes the similarities in these works, and this hardens into theory in the s and s, especially reinforced by the work of Caruth. It is at this point that the idea that trauma can only be represented through (post)modernist or avant-garde literary forms gains wide acceptance. According to the influential theories of Caruth and her followers, trauma is either beyond depiction or only representable through complex literary language: it ‘must . . . be spoken in a language that is always somehow literary: a language that defies, even as it claims, our understanding’. This is a wide-reaching assertion, and one which has had lasting effects on both trauma literature and criticism in the West, imposing formulae that in turn produce a narrow approved trauma aesthetic. The language used by theorists is instructive in terms of just how limiting critical writing becomes at this point. Laurie Vickroy, for example, discusses how ‘[a]uthentic trauma fiction’ is marked by the use of literary forms and language typical of (post)modernism. It is perhaps not surprising that such a prescriptive understanding of the phenomenon starts to limit representations of trauma’s effects and to produce an identifiable critically approved aesthetic. In order to understand this aesthetic further, it is worth briefly considering the types of techniques advocated by critics and frequently employed by trauma writers during this period. These techniques can be traced back directly to the understanding of trauma’s effects – such as belatedness, literality, and punctuality – advanced by Caruthian theory and PTSD. In both fiction and autobiography, belatedness and amnesia,
For a discussion of some of the paradigmatic trauma texts of this period – including Joseph Heller’s Catch-, Kurt Vonnegut’s Slaughterhouse-Five, E. L. Doctorow’s The Book of Daniel, and Toni Morrison’s Beloved – see Gibbs, ch. . Caruth, Unclaimed Experience, p. , original italics. Laurie Vickroy, Trauma and Survival in Contemporary Fiction (Charlottesville: University of Virginia Press, ), p. .
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for example, would typically be expressed through fragmented narratives characterized by analepses, digressions, diversions, and prevarications in narrative trajectory, and dispersal or fragmenting of narrating personae. Fragmentation here would be understood as simulating a traumatized sensibility, where the sufferer experiences difficulties ordering events, or separating the past from the present. Repetition in narration, often combined with repeated analepses, is similarly taken to evoke a character haunted by trauma flashbacks. Texts of this period are also often marked by discursive procrastination, where narrator-sufferers dwell on extraneous detail, or circle around elements only tangentially related to the instigating traumatic event. Such strategies are related to the notion that trauma must not be confronted too directly, since approaching traumatic memories ‘too precipitately leads to a fruitless and damaging reliving of the trauma’. The techniques employed by writers and approved by critics as supplying ‘authentic’ forms of trauma representation are thereby seen to simulate symptoms of trauma validated by the dominant trauma theorists. A groundswell of recent theoretical writing expresses disquiet on a number of grounds regarding the use of these critically approved techniques in the representation of trauma. One objection points to the antirealist bias in cultural trauma theory – Caruth’s ‘literary language’ – as not only prescriptive, but also failing to reflect clinical treatment of trauma. That is, while therapy tends to encourage sufferers to employ a realist and straightforward narrativization of their trauma, cultural trauma theory by contrast asserts that realist discourse undermines the sublime traumatic experience. Postcolonial critics have also objected that the prizing of (post) modernist literary devices and concomitant denigration of realism betrays a Western bias. Craps and Buelens, for example, note that many postcolonial trauma writers perceive ‘the Western discourse of unspeakability . . . as politically debilitating’. For writers from the developing world, in other words, the imperative is to communicate their story urgently and clearly, rather than to capture the ineffable sensation of trauma. More broadly, the narrow prescriptiveness of cultural trauma theory’s representational codes – what Luckhurst deemed the ‘implicit aesthetic for the trauma novel’ – risked homogenizing the actually diverse experience of trauma. This demonstrably encouraged a cohort of writers in Western literature who believed that there is a ‘correct’ way to portray trauma, and
See the discussion of Catch- later in this chapter for an example of this narrative strategy. Judith Herman, Trauma and Recovery (New York: Basic Books, ), p. . Craps and Buelens, p. . Luckhurst, p. .
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consequently also a formulaic genre of trauma texts. This ‘trauma genre’ draws upon a simplified and restricted range of those aspects of trauma theory most widely disseminated into Western culture. Trauma, in these texts, functions according to the dominant model’s criteria (belatedness, literality, punctuality) and is represented using the approved aesthetic norms. This body of trauma genre literature, moreover, developed in symbiotic relationship with a reinforcing criticism which approved every new literary text that emerged to reconfirm the theories. As Luckhurst suggests, texts were ‘often brought together by critics as exemplary works because they are held to share a particular trauma aesthetic. This is sometimes explicitly stated in prescriptive terms, listing elements that must be included to establish membership of a proper or authentic literature of trauma.’ Luckhurst is here correct, if we consider evidence of numerous articles and conference papers which simply evaluate a trauma text’s validity according to whether it conforms to the modes of representation established by Caruth’s theories. I wrote extensively on what I termed ‘trauma genre criticism’ – this unedifying circular process whereby writers adopt narrative forms derived from dominant elements of trauma theory, while critics in their turn bestow moral and aesthetic value on such representations – in my monograph, Contemporary American Trauma Narratives. There I bemoaned writers using trauma theory in order to write convincing accounts alongside critics’ complicit celebration of such works as validating their own theories, and also how this situation had blunted the initially disorienting and innovative character of the narrative forms typically employed. Thankfully, there is considerable evidence that criticism at least has advanced and significantly broadened in the last few years to begin to take account of mine and others’ critiques. There is, for
I discuss Jonathan Safran Foer’s Extremely Loud and Incredibly Close () in relation to this idea in ch. of Contemporary American Trauma Narratives. Other works which arguably demonstrate some of these formulaic tendencies include Anne Michaels’s Fugitive Pieces (), Pat Barker’s Another World (), Siri Hustvedt’s What I Loved (), and John Updike’s Terrorist (). The popularity of so-called misery memoirs, such as Frank McCourt’s Angela’s Ashes (), entrenched aesthetic formulae in the realm of non-fiction. So widespread was the acceptance of these aesthetic norms that authors such as Binjamin Wilkomirski (Fragments, ) and James Frey (A Million Little Pieces, ) were able to draw on them to fabricate apparent memoirs which were subsequently – and notoriously – exposed as fictional. Luckhurst, p. . See Gibbs, Contemporary American Trauma Narratives, especially pp. – and –. See, for example, Stef Craps, Postcolonial Witnessing (Basingstoke: Palgrave MacMillan, ) and Joshua Pederson, ‘Speak, Trauma: Toward a Revised Understanding of Literary Trauma Theory’, Narrative, , (), –.
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example, much less slavish adherence to Caruthian formulae and ‘checklist’ criticism, alongside greater acknowledgement of non-Western depictions of trauma and its effects. This is coupled with a markedly broader range of subjects comprising trauma literature – as the next section demonstrates – which would now include not only acute traumas but chronic conditions including the experiences of racism, colonialism, or gender-based violence.
Twentieth- and Twenty-First-Century Trauma Literature: Brief Case Studies This section discusses a selection of trauma texts which demonstrate diverse ways in which trauma manifests in cultural artefacts. Trauma as a dominant cultural paradigm is rooted in the West; notably, the majority of key theoretical and critical texts originated in America. Reflecting these origins and the theoretical pervasiveness, alongside some key strengths and weaknesses of the Western concept of trauma, the texts discussed are written by American authors. In particular, two of Toni Morrison’s novels – her most celebrated work, Beloved () and a later novel, Home () – both largely eschew approved representational norms, not least in order to dramatize trauma within the context of a structurally racist society. Texts discussed later in this section feature large-scale human catastrophes, which might be allegorically mapped onto notions of trauma induced by extreme anxiety concerning climate change. Before we consider Morrison’s work, it would be useful to cast a little further back, in order to trace the emergence of some key tropes of trauma representation, using one of the paradigmatic mid-twentieth-century American trauma texts. Predating Morrison’s career, Joseph Heller’s Second World War novel, Catch- (), provides rich examples of foundational representational practices which later became paradigmatic in the depiction of trauma. The key trauma in Catch- is somatic in origin, founded as it is on Yossarian’s delayed discovery that his companion in an aircraft during a combat mission, Snowden, is suffering a fatal shrapnel wound that has torn open his stomach. This episode is telling in at least two respects relevant to this chapter. Firstly, Yossarian’s psychic trauma originates in a wound to Snowden’s body, and secondly this wound is only discovered belatedly by Yossarian – when it is too late to help – underlining the allegedly deferred character of trauma. Snowden’s dying moments are only revealed in flashbacks towards the end of the novel, but do much to explain Yossarian’s foregoing behaviour as traumatized acting out. In this sense, the narrative structure of Catch- may be understood as a form of
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procrastination, slowly circling around this central trauma, as the reader encounters incremental additions to the Snowden story, whose totality is nevertheless continually deferred. While the spiralling narrative form of Heller’s novel becomes something of a trope of trauma narratives, in Catch- it is not, as in most later evocations, intended to evoke a supressed traumatic memory gradually recovered, as Caruth’s representational model would approve. Instead, Yossarian remembers all too well but refuses to relive the incident for most of the novel. That is, he remains lucid about and conscious of the causes of his trauma, even while Heller dramatizes Yossarian’s traumatized acting out in the novel’s absurd paradoxical logic and circular, repetitive structure. In terms of an embodied trauma based on the violation of a human body, Morrison’s Beloved () bears similarities to Catch-. Beloved depicts the traumatic effect of Sethe’s brutal solution to her fear of her daughter Beloved falling into slavery, and as in Heller’s novel, the traumatic incident itself is only fully narrated a considerable way into the novel. In a sense, Beloved significantly subverts trauma theory before it has fully emerged. On the one hand, the novel employs techniques which become familiar in later trauma texts, such as disruptions to chronology and the novel’s narrating voice, alongside extensive use of repetition and procrastination, which a number of the ex-slaves employ in their narration apparently as a means to avoid confronting traumatic memories. In confessing her actions to Paul D, for example, Sethe is described as physically ‘[c]ircling him the way she was circling the subject’. Synecdochal phrases are similarly employed in the manner of classically Freudian screen memories to obscure harrowing traumas. Sethe, for example, berates herself for involuntarily remembering trees rather than slaves who have been hanged from them: ‘Try as she might to make it otherwise, the sycamores beat out the children every time and she could not forgive her memory for that.’ Conversely, the strategies employed in Beloved notably challenge dominant strains of trauma theory. Like Catch, Morrison’s novel insists on the invading presence, in consciousness, of traumatic memory, rather than its absence or inaccessibility. As Jill Matus observes, ‘Sethe may choose not to tell or to “tell things halfway” only, but that does not mean she does not remember them.’ This carefully maintained distinction between memory and narration runs counter to prevailing theoretical perspectives. But while Beloved both challenges
Toni Morrison, Beloved (London: Vintage, ), p. . Morrison, Beloved, p. . Jill Matus, Toni Morrison (Manchester: Manchester University Press, ), p. .
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representational norms regarding trauma and thereby becomes itself a paradigmatic trauma text, this is problematic to the extent that lesser writers adopting similar formal techniques overlooked that Morrison had constructed them to broach incidences of trauma that were temporally and geographically specific. Published twenty-five years after Beloved, Home shares several concerns with Morrison’s earlier novel, both in terms of theme and form. The protagonist of Home is Frank Money, a -year-old African American veteran of the Korean War. During his short life Frank has been the victim of a number of traumas: his family was forced by whites – likely the Klan – to flee their home in Texas when he was four years old, during which time Frank witnessed a number of barbarous acts against the escaping black community. After an arduous journey, the family relocated with relatives to Lotus, a tiny town in Georgia. While their parents are out working, Frank and his baby sister Ycidra – born during the journey – are minded by their step-grandmother, who treats them cruelly, this long-term abuse producing evidence of insidious trauma in the adults, especially Ycidra. When aged respectively four and eight, Ycidra and Frank surreptitiously enter a local stud farm, where they witness – although this is only fully revealed late in the novel – a black father and son forced by whites to fight each other to the death. The father orders the son to kill him so that the son at least might be saved, and the novel opens with Frank’s sketchy memories of witnessing the father’s body’s burial. In adulthood, Frank leaves Lotus and its unwelcome associations, enlisting with two childhood friends, who are later killed in the Korean War, both incidents witnessed by Frank. On guard duty during the War, Frank also shoots dead a preadolescent Korean girl, who had been rooting through a rubbish dump for food, after she makes sexual advances to him. About a year after his discharge – already suffering from various posttraumatic effects – Frank is living in Seattle when he receives a letter telling him that his sister is in imminent danger. Back in Georgia she has been working for a white doctor, a eugenicist who has been using her as an experimental subject. The novel describes Frank’s journey across America to save his sister, while the last few chapters detail their partial recovery from their various traumas. For Morrison, and especially given what has taken place in the novel, this ending is unusually, albeit equivocally, optimistic. More characteristic is Home’s inventive treatment of trauma. The novel’s chapters strikingly alternate between third-person descriptions of the action and shorter, first-person monologues that originate from Frank
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and appear to be directed at the narrator of the other chapters. This dialogical relationship between the novel’s protagonist and its narrator means that the reader occasionally experiences considerable uncertainty regarding exactly what has happened in Frank’s past, and what is being described in the text’s present. Frank, for example, actively challenges the narrator’s representation of his focalized internal thoughts on more than one occasion. Morrison thus constructs a sense that the traumas Frank has experienced still affect the way he encounters the world. That is, Morrison’s traumatic metafiction – the way these dialogues cast doubt on what really occurred – vividly dramatizes the very real struggle to comprehend his past that Frank rehearses during his journey south. Two key traumatic incidents experienced by Frank are only accurately narrated late in the novel: the appalling father–son fight, and Frank’s murder of the young Korean girl. An oblique description of the first incident opens the novel, but the fight is omitted, with only a fleeting reference to the dead father’s foot, as he is buried. Frank ends the chapter explaining this to his interlocutor: ‘know this: I really forgot about the burial. I only remembered the horses. They were so beautiful. So brutal. And they stood like men.’ A full and accurate memory of this event is only recovered and narrated near the novel’s close, when Frank is told by older members of the community about the horrific forced fight between father and son. Following this revelation, Frank and Ycidra achieve a degree of recovery, exhuming the bones of the dead man, and wrapping them in a quilt made by Ycidra. The siblings rebury the bones in a newly dug and now marked grave, above which Frank inscribes, in a way which reflects his own growth through the novel, ‘Here Stands A Man’. Frank’s killing of the Korean girl is first described two-thirds of the way through the novel, but deceptively. On this first occasion, Frank relates witnessing another soldier, tellingly his ‘relief guard’, being propositioned by the girl, as she reaches for his crotch: ‘As soon as I look away from her hand to her face, see the two missing teeth, the fall of black hair above eager eyes, he blows her away.’ Much later, Frank reveals that it was actually he
Some critics actually collapse that narrator into Morrison herself. This merging of the narrator with Morrison has perhaps been encouraged by the author, who described the composition of the book as ‘let[ting] the character sit on my shoulder and talk to me’, an approach she describes as a ‘great discovery . . . so he and I are in this relationship’ (qtd. in Jan Furman, ‘Telling Stories: Evolving Narrative Identity in Toni Morrison’s Home’, in Toni Morrison: Memory and Meaning, ed. by Adrienne Lanier Seward and Justine Tally (Jackson: University Press of Mississippi, ), pp. – (p. )). Toni Morrison, Home (London: Chatto & Windus, ), p. , original italics. Morrison, Home, p. . Morrison, Home, p. , original italics.
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who killed the girl: ‘How could I like myself, even be myself if I surrendered to that place where I unzip my fly and let her taste me right then and there?’ This revelation is preceded by Frank’s confession to the novel’s narrator at the opening of this brief chapter: ‘I have to say something to you right now. I have to tell the whole truth. I lied to you and I lied to me. I hid it from you because I hid it from me.’ Belatedly in the novel, therefore, Morrison significantly alters the reader’s perspective on and sympathy for the chief protagonist. There is a startling distinction between the ways in which the two key traumatic events are registered in Frank’s memory and narrated. To recall, Frank states that he ‘really forgot about the burial’ following the knife-fight between the father and son, whereas Frank’s killing of the girl was deliberately hidden through his having ‘lied’. As in Beloved, Morrison is again focusing with precision on the fine details of traumatic memory. On one occasion in Home – witnessing the patricide – the events are involuntarily banished to Frank’s subconscious in a way roughly commensurate with Caruth’s model of trauma. By contrast, in the second instance – Frank’s killing of the girl – the events are consciously suppressed, recalled but initially not narrated, similarly to Sethe’s traumatic memories in Beloved. Like Sethe, Frank identifies in this instance as a perpetrator and so his memory experience of the trauma is categorically different. What Morrison seems to suggest in both Beloved and Home is that perpetrator trauma involves a dimension of moral injury and resultant guilt that makes it impossible for the traumatic memory to be consigned to the subconscious. Home thereby reveals that Morrison’s agility in employing inventive but appropriate means to depict trauma’s effects remained throughout her writing career. Like her other work, Home also details broader societal causes of trauma, in depicting institutional racism as a backdrop to Frank’s journey. Thus while Frank and Ycidra attain a significant measure of personal redemption through his saving her, his coming to terms with his responsibilities, and her realization that she can no longer rely on him, the broader canvas underlines the prejudice facing the African American community in the s. To an extent, little had changed since the world of Beloved. During his journey from Seattle to Georgia, Frank encounters or witnesses numerous micro- and macroaggressions. These include a
Morrison, Home, p. , original italics. Morrison, Home, p. , original italics. For more on moral injury and trauma, see Joshua Pederson, Sin Sick: Moral Injury in War and Literature (Ithaca: Cornell University Press, ).
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casually racist police stop-and-search in Chicago, meeting a boy who had his arm shot off by a white cop, and seeing a couple on a train viciously beaten up for using the white section of a café during a stop. The optimism of the novel is tempered, in other words: Frank and Ycidra’s personal redemption is set against this backdrop of structural racism, even as Frank’s journey is continually aided by black strangers he encounters, and Ycidra’s recovery is enabled through the rough care of the African American women in her home town. In Home, trauma is not individualized, and therefore it is neither medicalized nor depoliticized.
Epilogue: Climate Crisis and ‘Pre-Traumatic Experience’ In Home, as earlier in Beloved, bodily experiences operate not only as a cause, but also as an approximate objective correlative of chronic trauma. Trauma is actually embodied in the scarred female body, in other words, but also works symbolically. This is a trend detectable in a range of contemporary American fiction which might be loosely connected in terms of representational practices associated with climate change. A number of theorists have begun to suggest, albeit tentatively, that a notion of collective ‘pre-traumatic experience’, or pre-TSD comprising symptoms similar to PTSD but instigated by anxieties related to global warming, may hold some value. Lucy Bond and Stef Craps, for example, discuss the work of theorists Paul Saint-Amour and E. Ann Kaplan, both of whom have speculated in this area, and conclude that their work suggests ‘that we may now be entering a new era characterized by pervasive pre-trauma, in which people live in fear of a catastrophic future marked by environmental crisis’. Urging caution, Bond and Craps note that ‘[i]n the absence, as yet, of sound empirical evidence, it is unclear whether this collective anticipatory anxiety does indeed amount to trauma in the clinical sense’, and so they regard climate-related pre-TSD as currently hypothetical. Nevertheless, if literature is a barometer of the surrounding culture, then this range of contemporary texts strongly suggests a shared set of anxieties surrounding global warming. In these novels, pre-traumatic anxiety regarding the fate of humankind is arguably detectable through embodied traumas undergone by characters in pre- and post-apocalyptic scenarios.
Lucy Bond and Stef Craps, Trauma (New York: Routledge, ), p. . Bond and Craps, p. . The striking proliferation of specifically American ‘pre-TSD’ climate texts is why they are the focus of this section, notwithstanding that as the term suggests, global warming is a planet-wide issue.
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An obvious touchstone in this respect is Cormac McCarthy’s The Road (), wherein a young boy and his father trek across a barren, postapocalyptic American landscape (although the precise nature of the apocalypse, as in a number of these fictions, is unclear). The man suffers from a worsening cough throughout the novel, and this chronic illness, exacerbated by his being shot with an arrow, eventually kills him. The man’s physical debilities are shared by the boy – who at one point suffers a protracted fever – and mirrored by the boy’s mental condition. Several times during the novel – for example after the two of them find an abandoned fire with a baby roasted on a spit – the boy mentally withdraws, unable to speak, suffering identifiable symptoms of trauma. After this incident, the father wonders whether the boy will ever speak again, and notes that ‘[e]ven a year ago the boy might sometimes pick up something and carry it with him for a while but he didnt [sic] do that anymore’. The novel thus features a ravaged world in which characters are suffering both physical and mental traumas, and may be taken as a precursor of a more recent trend for novels that link embodied trauma to a broader sense of humankind in peril. Rumaan Alam’s Leave the World Behind (), for example, depicts an America thrown into creeping panic by power blackouts and assaults from a mysterious noise, most likely a sonic boom from overhead combat aircraft. The novel’s protagonists appear to undergo a collective insidious trauma, brought on partly by anxiety over a lack of information about the developing apocalyptic scenario. As with The Road, although the precise nature of the threat is unclear – and not explicitly related to climate change – the novel expresses the kind of pre-traumatic anxiety linked to global warming that I have mentioned. Moreover, as with Home and The Road, trauma in Leave the World Behind is symbolized also in part as physical assaults on the body. The protagonists’ son’s teeth mysteriously fall out following his exposure to the noise, for example, while the adults experience various bouts of nausea and confusion. Similarly, in Alexandra Kleeman’s Something New Under the Sun (), overriding ecological disaster linked to climate change features alongside an epidemic of early-onset dementia. Against this novel’s backdrop of burning Californian forests, numerous characters begin to suffer amnesia, a symptom typically associated with psychological trauma. Once more, apparent anxiety about climate change is expressed through medical symptoms suggesting embodied traumas. Finally, Ruth Ozeki’s The Book
Cormac McCarthy, The Road (London: Picador, ), p. .
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of Form and Emptiness () features the trauma and mental illness of Benji and his mother Annabelle, following the violent death of her husband. Benji is subsequently plagued by a sense that inanimate objects are speaking to him and giving him orders, while Annabelle’s tendency to hoard materials ultimately overruns their home. As with Kleeman’s novel, these traumatic reactions play out before a backdrop of climate-changeinduced eco-disaster and burning Californian forests. In all these cases, psychological trauma linked to physical assaults on the body functions similarly to trauma in those earlier texts, both as specific examples of the phenomenon and as metaphors for the pre-traumatic anxiety induced by impending ecological disaster. These novels of pre-traumatic anxiety may be conceived as part of a general widening of the concept of trauma that this chapter has discussed. Following numerous challenges to the originally narrow and Westernbiased theories of PTSD and Caruthian cultural trauma theory, the concept has gradually broadened and sought new directions. Trauma is, for example, now less focused on individual pathologies, and therefore more politicized, thanks not least to interventions from postcolonial critics and writers. As we have seen, Morrison’s depictions sound an angry condemnation of a society that has institutionalized racial traumas. Novels of pre-traumatic climate anxiety similarly locate individual and collective traumas against a societal backdrop, and are not afraid to advocate political change. The source of dementia in Kleeman’s Something New, for example, is linked to a shady corporation that promotes ‘WAT-R’, a synthetic water popular in California. Traumatic suffering is in this case directly related to capitalist corporations. It is to be hoped that the new energies imbuing the concept continue to find further value in understanding trauma in the context of political and social dynamics.
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Developments: Forms
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Illness and the ‘Fall’ of Language Steven Wilson
Introduction Focusing on illness narratives, this chapter analyses how patient-writers use language to translate the corporeal experience of illness and, in the process, how they express what it means to be ill. Virginia Woolf, in her essay ‘On Being Ill’, famously suggests that patients have a ‘shallow reservoir’ of possibilities for articulating illness: ‘let a sufferer try to describe a pain in his head to a doctor and language at once runs dry’. Yet Woolf holds out the possibility that, faced with a paucity of directly expressive words for articulating illness, a ‘new language’ might emerge, one in which the patient ‘[i]s forced to coin words himself’. It is precisely the use of language to communicate a patient’s experience of illness which this chapter discusses. In line with the conceptual aims of the critical medical humanities, it does not simply examine the ways in which writing about illness serves as a response to the silencing effect a moment of diagnosis can produce; rather, it analyses the ways in which language is mobilized to communicate the embodied experience of being a patient. The chapter focuses on processes of writing and reading. It asks how writing about illness in pathographies or other accounts allows patients to resist ceding control of their experience to the dominance of medical jargon. This is important because, as gastroenterologist Fergus Shanahan has argued in his book on how language can act as a barrier in the doctor–patient relationship, ‘doctors use disease-words whereas patients speak illness-language’.
Virginia Woolf, ‘On Being Ill’, in The Essays of Virginia Woolf, ed. by Andrew McNeillie, vols. (London: Hogarth Press, ), IV, pp. – (p. ). Woolf, pp. –. Fergus Shanahan, The Language of Illness (Dublin: Liberties Press, ), p. vii. In English, ‘disease’ and ‘illness’ are separate linguistic categories, with the former indicating a ‘pathological process, deviation from a biological norm’, and the latter ‘a feeling, an experience of unhealth which is entirely personal, interior to the person of the patient. Often it accompanies disease, but the disease may be undeclared.’ See Kenneth M. Boyd, ‘Disease, Illness, Sickness, Health, Healing and
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The final section of the chapter then analyses the extent to which reading narratives of illness can help patients to understand, and in turn find a linguistic framework to articulate, what it means to be ill. What is revealed is that narrative accounts of illness draw from a rich array of linguistic resources, particularly metaphors rooted in the world of geopolitics, but that some patient-writers move well beyond conventional language, encouraging the reader to enter into a more politically engaged response to illness.
The ‘Fall’ of Language Alexander Stern, in The Fall of Language, explores the nature of meaning by placing Walter Benjamin’s philosophy of language into dialogue with Ludwig Wittgenstein’s. Benjamin argues that language is an allencompassing medium of expression in which everything shares: all things express meanings, and human language does not impose meaning on the objective world but translates the world around us – that is, ‘transforms and reconfigures its already extant meaning’. He describes the transformations that language as such undergoes while making its way into human language as the ‘fall of language’. For Stern, ‘the expansions of the concepts of language and translation thus entail another expansion, that of the concept of experience, which is now to be understood not in terms of the receipt and ordering of sensations but the communication of meaning’. While Stern is concerned with language as a philosophical concept, the implications of his analysis bear a particular significance in the articulation of illness, in which allusions or direct references to ‘falling’ echo strongly in narrative reflections on how language may be used to translate the experience of being ill. American poet and essayist Anne Boyer has written extensively about her diagnosis (a week after her forty-first birthday) and treatment for a highly aggressive form of breast cancer. In , Boyer was awarded the Pulitzer Prize for General Non-fiction for her book The Undying: Pain, Vulnerability, Mortality, Medicine, Art, Time, Dreams, Data, Exhaustion, Cancer, and Care. As hinted at by the subtitle of the American version, the text weaves together a series of reflections on issues ranging from the gendered politics of illness to the pharmaceutical industry and the cultural
Wholeness: Exploring Some Elusive Concepts’, Medical Humanities, , (), – (p. ). Interestingly, in other languages, such as French, this linguistic distinction does not hold. Alexander Stern, The Fall of Language: Benjamin and Wittgenstein on Meaning (Cambridge, MA: Harvard University Press, ), p. . Stern, p. . [accessed May ].
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or digital forms that give expression to mortality. Transcending the book, however, is a keen awareness of the impact of illness on language – and vice versa. Near the beginning of her account, Boyer writes: We fall ill, and our illness falls under the hard hand of silence, falls onto slides under confident microscopes, falls into pretty lies, falls into pity and public relations, falls into new pages open on the browser and new books on the shelf. Then there is this body (my body) that has no feel for uncertainty, a life that breaks open under the alien terminology of oncology, then into the rift of that language, falls.
Boyer’s repeated use of the verb ‘fall’ reflects the lack of control that many patients feel when diagnosed with an illness, particularly a serious or terminal one. To ‘fall’ ill in English, ‘tomber malade’ in French or ‘cair doente’ in Portuguese is, seemingly, to be reduced to a state of isolation and powerlessness. In the void, the language used to describe the illness in question and to give expression to the diseased body is often driven by science and its subfield, medicine. As patients submit their trust – and their body – to the authority and knowledge of medics, they simultaneously cede control of their subjective story. Sociologist Arthur Frank has thus concluded that ‘illness often takes away the [patient’s] voice’. In this way, patients must negotiate the ‘fall of language’ if they are to communicate the meaning of being ill. Boyer experiences the appropriation of voice through medicine’s translation of bodily symptoms into data: ‘Patients become information . . . via the quantities of whatever emerges from or passes through their discrete bodies’, with the consequence that ‘the bodies and sensations of entire populations become the math of likelihood (of falling ill or staying well, of living or dying, of healing or suffering) upon which treatment is based’. Turning to the Internet to try to connect with other patients’ experiences of breast cancer, she discovers that medical authority is such that patients readily adopt the specialist language of medicine to give expression to their phenomenological reality: My fear wasn’t of cancer itself, about which I knew almost nothing then. My fear came from a search engine. I was afraid of what Google gave back
Anne Boyer, The Undying: A Meditation on Modern Illness (London: Allen Lane, ), p. . This abbreviated subtitle is used in the European edition. It is important to note, however, that the linguistic framing of illness as a ‘fall’ does not work in all languages. For example, the German phrase ‘krank werden’ places the focus more on ‘becoming’. Arthur W. Frank, The Wounded Storyteller: Body, Illness, and Ethics (Chicago and London: University of Chicago Press, ), p. xii. Boyer, p. .
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to me when I entered ‘breast lump’ into it, afraid of the culture of disease as circulated on blogs and on discussion boards, afraid of how people were turned into patients with handles and signatures, agonies, neologisms, and encouragements. Mets. Foobs. NED. I was afraid, on the first day, for my vocabulary.
For Boyer, the patient’s borrowing of medical jargon represents an infringement on selfhood. As ‘my vocabulary’ is usurped by the proliferation and circulation of medical discourse, the patient, who would have presented for medical diagnosis in the first instance with her own story, finds herself displaced from the role of author or storyteller, having yielded control of her narrative to medicine. Moreover, the patient exchanges her language for the lingua franca of medicine. As Frank puts it, ‘ill people surrender their bodies to medicine’, as physicians ‘assert authority as scientists by imposing specialised language on the patient’s experience’. The ‘fall’ of language experienced by the ill person is, then, catalysed by enforced medical authority, or what Frank terms the ‘medical colonisation’ of the body; that is, the ‘claiming of the body of the patient as its territory’. The metaphor of colonialism used to describe doctor–patient dynamics draws attention to the language of violation in conceptualizations of illness that focus on the usurpation of the patient’s language – or what is frequently referred to as the ‘patient’s voice’. Neurologist and writer Oliver Sacks, described by the New York Times as ‘a kind of poet laureate of contemporary medicine’ due to the lyrical qualities of his prose, wrote poignantly in in the same newspaper of learning he had terminal cancer. In a previous publication, Sacks noted that, for patients who receive news of a serious illness, ‘a world is lost or broken or unmade, reduced to bits and pieces, to chaos’. By evoking illness in territorial terms, and specifically by connecting it to a violently transformed space,
Boyer, p. . As Oliver Sacks frames it, the ‘clinical tale’ is the form ‘which patients adopt when they present themselves, in distress, to their doctors. The patient presents a medical “history” – a story of how he or she has been feeling, what he or she has been experiencing, in the realm of “illness”.’ Oliver Sacks, ‘Clinical Tales’, Literature and Medicine, (), – (p. ); emphasis in original. Frank, pp. , . Frank, p. . Cited in ‘Oliver Sacks: The Visionary Who Can’t Recognise Faces’, The Guardian, October
[accessed May ]. ‘My Own Life: Oliver Sacks on Learning He Has Terminal Cancer’, The New York Times, February [accessed May ]. Sacks, p. .
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Illness and the ‘Fall’ of Language
Sacks echoes some of the language used by Frank, while evoking Heidegger’s notion of the ‘Unheimlich’, the primordially estranged state in which we are alienated from our world, and which encompasses the fear, anxiety, and social isolation that illness produces. Susan Sontag has also conceptualized illness in spatial language: ‘Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.’ Many critics have nonetheless pointed to the irony of Sontag’s statement, given that she famously argued that ‘the most truthful way of regarding illness – and the healthiest way of being ill – is one most purified of, most resistant to, metaphoric thinking’ because of the negative, stigmatizing implications of seeing patients as afflicted or embattled. While such metaphors provide a language that allows patients to make sense of their illness, they are frequently not – returning to Boyer – ‘my vocabulary’; that is, the vocabulary of someone who often does not think of themselves as living in a clearly demarcated kingdom but rather, as the French writer Hervé Guibert, suffering from HIV-AIDS, puts it, ‘dans cette frange d’incertitude, qui est commune à tous les malades du monde’ [‘along this borderline of uncertainty, so familiar to all sick people everywhere’]. On the fringes of society – isolated, stigmatized, quarantined, or even hospitalized – how do patients find a vocabulary that allows them to take control of their experience and negotiate the ‘fall’ of language? In line with the conceptual aims of this volume, the analyses in the following sections of this chapter consider the reciprocal relationship between illness and language as generated through narrative – specifically, through the practices of writing and reading.
Writing Illness Telling the story of illness permits the patient ‘to give voice to an experience that medicine cannot describe’. The process of ‘giving voice’ to
Martin Heidegger, Being and Time, trans. by John Macquarrie and Edward Robinson (New York: Harper & Row, ), pp. –. Susan Sontag, Illness as Metaphor & AIDS and Its Metaphors (London and New York: Penguin, ), p. . Sontag, p. . Hervé Guibert, À l’ami qui ne m’a pas sauvé la vie (Paris: Gallimard, ), p. ; Hervé Guibert, To the Friend Who Did Not Save My Life (London: Serpent’s Tail, ), p. . Frank, p. .
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illness has been at the core of medical humanities-inflected studies in recent years, with written accounts of the ‘patient’s story’ – often referred to as pathographies or autopathographies – at the core of that research. Anne Hunsaker Hawkins, in her extensive study of the genre, has suggested that it is precisely by giving the patient a voice that pathography ‘restores the person ignored or canceled out in the medical enterprise’ and ‘places that person at the very center’. Pathography, then, ‘returns the voice of the patient to the world of medicine . . ., and it does so in such a way as to assert the phenomenological, the subjective, and the experiential side of illness’. In this way, pathography might be regarded as a complementary text to the patient’s medical history or case reports as transcribed by a physician, many of which include literary figures such as metaphors. While a medical history will record a diagnosis, symptoms, and a treatment plan, a pathography will focus much more on the experiential side of illness, giving voice – a ‘voice uncontained by medical professional dominance’ – to the patient. The implications for patients in writing their illness story have been the subject of sustained attention. For Frank, illness stories can have a reparative function, allowing the self to be ‘formed’ – or possibly reformed – ‘in what is told’. In his analysis of different types of narrative (restitution narrative; chaos narrative; quest narrative; testimony), Frank posits that the overarching benefit to the patient of translating their illness into a story is that the ailing body is turned from a ‘thing that is described’ into a medium through which their experience is given ‘particular shape and direction’. In their shift from passive entity to active agent, patient-storytellers counter the silencing tendencies of professional medicine. Many scholars have argued that it is precisely narrative’s form and structure that support the aim of liberating the patient’s voice. Arthur Kleinman, for instance, has emphasized narrative’s potential for reestablishing coherence and, therefore, meaning in the life of a sufferer: The illness narrative is a story the patient tells, and significant others retell, to give coherence to the distinctive events and long-term course of suffering. The plot lines, core metaphors, and rhetorical devices that structure the illness narrative are drawn from cultural and personal models for arranging experiences in meaningful ways and for effectively communicating those meanings.
Anne Hunsaker Hawkins, Reconstructing Illness: Studies in Pathography, nd edn (West Lafayette: Purdue University Press, ), p. . Hunsacker Hawkins, p. . Frank, p. . Frank, p. . Frank, p. . Arthur Kleinman, The Illness Narratives (Oxford: Oxford University Press, ), p. .
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Thomas R. Cole, Nathan S. Carlin, and Ronald A. Carson go further, stating that while ‘[s]erious illness and injury are especially powerful events that interrupt the largely unself-conscious flow of our lives’, they also ‘prompt the impulse to emplot them, that is, shape them into a liveable story, a narrative of an experience of illness’; narrative, thus, ‘shapes our experience of brute fact into intelligibility and meaningfulness’. That said, other recent studies have pointed to the rich potential inherent in non-narrative forms, for example by underlining that it is precisely in textual fragmentation that we find authentic expressions of what it is to undergo illness. There remains important work to be done in analysing the capacity and potential for non-narrative expressions of the various facets of illness to be captured through poetry, blogs, social media, and other forms. From the perspective of the present study, however, it is the language used to frame narrative expressions of illness that is of interest. If the patient’s voice is to be mobilized to productive effect in pathography, what influences condition the language that serves as a vehicle for the translation and articulation of what it means to be ill? Anne Whitehead and Angela Woods, in their call for a more ‘critical’ medical humanities, have challenged those working in the field to move beyond what they term the ‘primal scene’ of the medical humanities, namely the moment of cancer diagnosis. Their Edinburgh Companion to the Critical Medical Humanities builds on a landmark issue of the journal Medical Humanities. In their introductory article, the editors of that special issue argue for a critical medical humanities in which greater attention is paid ‘not simply to the context and experience of health and illness, but to their constitution at multiple levels’. As Woods and Whitehead have posited, the concept of ‘entanglements’ – that is, points of intersection where different categories meet – is central to a critical medical humanities.
Thomas R. Cole, Nathan S. Carlin, and Ronald A. Carson, Medical Humanities: An Introduction (Cambridge: Cambridge University Press, ), pp. –. In this book, the authors trace the development of pathography from the mid-twentieth century and focus on case studies which cover the loss of bodily integrity, mental collapse, disfiguring cancer, and incurable degenerative disease. See, for example, Angela Woods, ‘The Limits of Narrative: Provocations for the Medical Humanities’, Medical Humanities, , (), –. Anne Whitehead and Angela Woods, ‘Introduction’, in The Edinburgh Companion to the Critical Medical Humanities, ed. by Anne Whitehead and Angela Woods (Edinburgh: Edinburgh University Press, ), pp. – (pp. –). William Viney, Felicity Callard, and Angela Woods, ‘Critical Medical Humanities: Embracing Entanglement, Taking Risks’, Medical Humanities, , (), – (p. ). Whitehead and Woods, p. .
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In exploring the language of illness, the coalescence of biomedicine with political and historical factors has led to the emergence of a geopolitically inflected language that has become a hallmark of expressions of the diseased body. The arrival of syphilis in Europe was identified with Columbus and his fellow explorers; the worldwide flu of was called ‘Spanish influenza’ because the first cases were diagnosed in Spain; and President Trump infamously attempted to displace blame for the rising number of coronavirus cases in the USA by labelling it the ‘Chinese virus’. As Laura Otis has demonstrated, the nineteenth century, particularly with the development of cell and germ theory from onwards, gave rise to a scientific and wider cultural consciousness about the borders that mediate human contact: Germ theory, the idea that infectious diseases are caused by living microorganisms, encourages one to think in terms of ‘inside’ and ‘outside’ to an even greater extent. If one believes that invisible germs, spread by human contact, can make one sick, one becomes more and more anxious about penetration and about any connection with other people.
The pathological anxiety about the dangers of contact in the nineteenth century was mapped onto the wider political context of the time, giving rise to the military metaphor in medicine. What Otis has termed the ‘affinity between political and biological thinking’ in the nineteenth century shaped a language that is still commonly used to evoke patient experience. Discourses of invasion and infiltration may be seen as constituting an early version of the now ubiquitous militarized rhetoric that Sontag has suggested first developed in the late nineteenth century with the identification of bacteria as agents of disease, but which, over time, came to designate diseases in general, casting them as ‘evil predators’, ‘demonic enemies’, and ‘alien others’. When microorganisms came to be seen as an ‘invasion of alien organisms’, military metaphors of defence and war began to dominate linguistic descriptions of the diseased body; in turn, the body had to mount ‘its
As Frank notes, while most scholars differentiate disease as a ‘physiological process’ from illness as a ‘social experience of that disease’, the ‘notion of illness as embodied deconstructs the distinction: the illness experience is an experience in and of a diseased body’ (p. , n. ). Laura Otis, Membranes: Metaphors of Invasion in Nineteenth-Century Literature, Science, and Politics (Baltimore and London: Johns Hopkins University Press, ), pp. –. For more on the literary inscription of the martial metaphor, see, in a French context, Steven Wilson, The Language of Disease: Writing Syphilis in Nineteenth-Century France (Oxford: Legenda, ); and, in an anglophone context, Lorenzo Servitje, Medicine Is War: The Martial Metaphor in Victorian Literature and Culture (Albany: SUNY Press, ). Otis, p. . See Sontag, pp. –.
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Illness and the ‘Fall’ of Language
own military operations, such as the mobilizing of immunological “defences”’. So pervasive has this militarized language been that still today its influence is apparent in phrases such as ‘the fight against cancer’, ‘the war on AIDS’, or the ‘frontline heroes’ who ‘battle against COVID’. While martial metaphors are often appropriated in political discourse (to ‘rally’ the nation, for example), they also circulate freely in literary accounts of illness. For instance, Guibert, whose books have been translated into many languages, publicly revealed his HIV status and the story of his illness in his autofictional text À l’ami qui ne m’a pas sauvé la vie (published in English as To the Friend Who Did Not Save My Life). In it, Guibert frames the AIDS virus as ‘attacking’ the body: ‘On dit que chaque réinjection du virus du sida par fluides, le sang, le sperme ou les larmes, réattaque le malade déjà contaminé’ [‘It’s said that each reintroduction of the AIDS virus through bodily fluids – blood, sperm, tears – renews the attack on the already infected patient’]. Extending the military metaphor, he goes on to describe his diseased body as a battlefield – ‘je suis très attentif aux manifestations de la progression du virus, il me semble connaitre la cartographie de ses colonisations, de ses assauts et de ses replis, je crois savoir là où il couve et là où il attaque’ [‘I pay close attention to the virus’s progress, I feel as though I know by heart the map of its colonizations, its assaults and retreats, I think I know where it’s lying in wait and where it’s on the advance’]. That said, this is a ‘battlefield’ on which resistance – ‘la lutte du corps contre les assauts du virus’ [‘the body’s struggles against the attacking virus’] – is mounted. The use of the military metaphor – or, indeed, any metaphor – provides a means for communicating (and, therefore, sharing) an experience of illness in accessible language, free from medicalized jargon. It is notable that even patients who have been scientifically trained are susceptible to its influence. When the American neurosurgeon and writer Paul Kalanithi’s memoir of stage IV metastatic lung cancer was posthumously published in , it became an immediate bestseller. A graduate of Yale Medical School, Kalanithi was on course to become one of America’s most respected physicians. Yet illness ‘interrupts’ his career and life more
Sontag, p. . For a detailed discussion of international uses of the military metaphor in the context of the COVID- pandemic, see The Languages of COVID-: Translational and Multilingual Perspectives on Global Healthcare, ed. by Piotr Blumczynski and Steven Wilson (London: Routledge, ). Guibert, À l’ami, p. ; To the Friend, p. . Guibert, À l’ami, p. ; To the Friend, p. . Guibert, À l’ami, p. ; To the Friend, p. .
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generally, to reprise one of the common motifs of pathographies. In his ontological shift from doctor to patient, Kalanithi moves from an ‘objective’ language of scientific diagnosis and prognosis to a more metaphorical language that encapsulates how he perceives his body. In the prologue to the book, he writes: I flipped through the CT scan images, the diagnosis obvious: the lungs were matted with innumerable tumors, the spine deformed, a full lobe of the liver obliterated. Cancer, widely disseminated. I was a neurological resident entering my final year of training. Over the last six years, I’d examined scores of such scans, on the off chance that some procedure might benefit the patient. But this scan was different: it was my own.
Kalanithi’s recourse to the language of ‘obliteration’ and ‘dissemination’ frames his body – now the body of a patient suffering from an illness – as a passive entity undergoing a hostile subversion. Later in the book, when he reflects on the image of the CT scan, he states: ‘With the cancer having invaded multiple organ systems, the diagnosis was clear.’ Illness is thus coded by Kalanithi as an antagonist assailing the bodily defences of the vulnerable patient. As Priscilla Wald has shown, such language is commonly used in modern narratives documenting viral infections whereby, in the use of ‘metaphors of aggression’, viruses are seen to ‘attack’, ‘devour’, and ‘destroy’ the body by ‘intruding’ into a host cell. Yet even in the case of a non-contagious illness such as cancer, metaphors of aggression can be effective in capturing the sense of despair felt by the patient, especially at the moment of diagnosis. While there has been much debate in recent years on the role and effectiveness of metaphors in articulating the experience of illness, Shanahan makes the key point that metaphors ‘create opportunity for a common language shared by patients and doctors’. For American writer, feminist, and civil rights activist Audre Lorde, writing about her experience of breast cancer and mastectomy forms the strategic centrepiece of a ‘war against despair’. Instead of framing illness as a war taking place in the
See, for example, Frank (esp. pp. –), who explains that illness interrupts or fragments the ‘coherent sense of life’s sequence’ (p. ). Paul Kalanithi, When Breath Becomes Air (London: Vintage, ), p. . Kalanithi, p. . Priscilla Wald, Contagious: Cultures, Carriers, and the Outbreak Narrative (Durham and London: Duke University Press, ), p. . Shanahan, p. . Audre Lorde, The Cancer Journals. Special Edition (San Francisco: aunt lute books, ), p. . For more on Lorde’s writing as resistance, see Cynthia Wu, ‘Marked Bodies, Marking Time: Reclaiming the Warrior in Audre Lorde’s The Cancer Journal’, a/b: Auto/Biography Studies, , (), –.
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Illness and the ‘Fall’ of Language
body, Lorde sees in the act of writing an opportunity – to reprise Shanahan’s term – to use language to forge connections with patients in similar situations, yet who may feel voiceless and powerless. Lorde is thus motivated by ‘the transformation of silence into language and action’. Driven by a conviction that her feelings and experience of illness must be ‘of use’, Lorde, in her writing, wages a ‘war against the tyrannies of silence’. Writing becomes a political act, and Lorde’s Cancer Journals function as a sort of rallying cry to other women who experience shame and victimhood amidst deeply embedded structures of misogyny that operate even in the context of illness: [W]omen with breast cancer are warriors, also. I have been to war, and still am. So has every woman who had had one or both breasts amputated because of the cancer that is becoming the primary physical scourge of our time. For me, my scars are an honorable reminder that I may be a casualty in the cosmic war against radiation, animal fat, air pollution, McDonald’s hamburgers and Red Dye No. , but the fight is still going on, and I am still a part of it. I refuse to have my scars hidden or trivialized behind lambswool or silicone gel.
Lorde’s war on silence and commitment to voicing her experience point to the sense of connection, power, and purpose that the act of writing illness can afford. All patients arguably form part of a minoritized community, yet some patient groups are always more silenced than others. For Lorde, writing about mastectomy is intended to offer ‘encouragement for other women to speak and to act out of our experiences with cancer and with other threats of death, for silence has never brought us anything of worth’. Notwithstanding that writing about illness affords various degrees of power to different groups, the very act of voicing the patient’s experience always militates against structures of authority that may not be intended to, but nonetheless have the effect of, silencing and marginalizing individuals. In this way, activism and lobbying often play a key role in written accounts of illness. By using the language of resistance to translate medical experience, the patient reframes illness writing as a politically engaged act.
Reading Illness Given that illness and, ultimately, death are axiomatic truths of human experience, even if – or perhaps, precisely because – mortality remains a
Lorde, p. .
Lorde, pp. , .
Lorde, pp. –.
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Lorde, p. .
profoundly engrained cultural taboo in many parts of the world, reading illness memoirs can dispel myths and, in certain cases, offer connection, or even identification, with those who undergo types of illness. At the very least, reading can provide linguistic and cultural frameworks that help us to understand experiences that are difficult to put into words. During the COVID- pandemic, there was an upsurge in reading, and not just among those in confinement because they had contracted the SARSCoV- virus. Famously, Albert Camus’s allegorical novel La Peste [The Plague] found itself a best-seller once again, reinforcing the cultural sense that we understand the spread of disease between and within bodies as an act of invasion. As Samuel Earle wrote in the New Statesman on the boom in ‘pandemic-lit’, ‘[s]ometimes we turn to novels to make sense of our world, and sometimes to escape it. Yet in hard times, we often ask them to do both at once: to make sense of our world, all the better to escape it.’ The concept of bibliotherapy has been shown to be particularly helpful to many people coping with the challenges of emotional or mental health. Yet it is important to recognize that those who write about their experience of illness are also readers – of their bodies, of their symptoms, and of the initial drafts of their attempts to give voice to what, for them, it means to be ill. In the process of reading and writing, followed by rereading the linguistic frameworks he adopts to articulate what he feels, Guibert forms an embodied relationship with his text, noting that his manuscript functions as ‘un compagnon, un interlocuteur, . . . le seul ami présentement tenable’ [‘a companion, someone with whom I can talk . . . the only friend whose company I can bear at present’]. Kalanithi relates how, even before he could find the words to give meaning to his life with terminal illness, reading literature – rather than scientific publications – provided ‘a vocabulary’ that allowed him to better understand, and therefore frame, his own story: I was searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again. The privilege of direct experience had led me away from literary and academic work, yet now I felt that to understand my own direct experiences, I would have to
Samuel Earle, ‘How Albert Camus’s The Plague Became the Defining Book of the Coronavirus Crisis’, New Statesman, May [accessed May ]. See, for example, Emmanuel Stip, Linda Östlundh, and Karim Abdel Aziz, ‘Bibliotherapy: Reading OVID during COVID’, Frontiers in Psychiatry, () . Guibert, À l’ami, p. ; To the Friend, p. .
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Illness and the ‘Fall’ of Language
translate them back into language. Hemingway described his process in similar terms: acquiring rich experiences, then retreating to cogitate and write about them. I needed words to go forward. And so it was that literature brought me back to life during this time.
Once again, blurring the boundaries between reading and writing, Kalanithi records in his illness memoir how the act of reading literature was life-giving, precisely because it provided him with a language with which to relate his plight, at a time when scientific knowledge only compounded his feeling of being ‘lost’. As Cole and others have noted, illness writers often strive ‘to make existential sense’ of their experience ‘by placing it in the context of a larger narrative of suffering and loss or healing, and then, in that light, giving a plausible account of what is happening now’. Reading other accounts in literature is a significant way of gaining access to that ‘larger narrative’. American writer Anatole Broyard affirms this in his account of being diagnosed with prostate cancer when he records his powerful identification with Shirley Hazzard’s novel of love in the midst of anguish, The Transit of Venus: ‘I burrowed into the book. I was not escaping into it but identifying with it as fervently as I have ever identified with any novel. . . . Her book was the prescription I needed and that no doctor could give me. I needed a dose of the sublime.’ Broyard’s reference to the ‘sublime’ may initially be perceived as an allusion to literature’s capacity for distraction. But Broyard makes clear that it was in reading literature that he was able to reformulate his illness from a personal tragedy into a creative challenge – and one centred on the capacity to forge a language adequate to the task of capturing his experience: So much of a writer’s life consists of assumed suffering, that I felt something like relief, even elation, when the doctor told me that I had cancer of the prostate. Suddenly there was in the air a rich sense of crisis – real crisis, yet one that also contained echoes of ideas like the crisis of language, the crisis of literature, or of personality.
Broyard declares that stories, in all their guises, are ‘antibodies against illness and pain’: ‘When various doctors shoved scopes up my urethral canal, I found that it helped a lot when they gave me a narrative of what they were doing. Their talking translated or humanized the procedure. It prepared,
Kalanithi, pp. –. Cole, Carlin, and Carson, p. . Anatole Broyard, Intoxicated by My Illness, and Other Writings on Life and Death (New York: Fawcett Columbine, ), p. . Broyard, p. .
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strengthened, and somehow consoled me. Anything is better than an awful silent suffering.’ His call for doctors to provide a humanized description – or story – of medical procedures is a much neglected, though potentially useful, element in medical communication and relationships. Yet, in medical education, doctors are more often taught the importance of carefully ‘reading’ the patient’s story and establishing communicative bonds with the ill person. As Shanahan has put it, while traditionally doctors have attempted ‘to translate the patient’s ordinary description of their symptoms into medical-speak’, the result has in fact been an ‘interpretation’ that risks losing the precise nature of the patient’s experience; pleading for more attention to be paid to the ‘source text’, Shanahan notes that ‘[t]he patient’s exact words are more revealing’ than a physician’s rewriting. In precisely this spirit, Rita Charon developed the pioneering concept of ‘narrative medicine’ to argue that the narratives of patients should form the basis of humanistic, patient-centred medical practice. Close attention to the use of language lies at the heart of narrative medicine, which is based on what Charon calls ‘narrative competence’, whereby a medic uses ‘the narrative skills of recognizing, absorbing, interpreting and being moved by the plights of patients in all their complexity’. As a result, the medic is better placed to translate their ‘close reading’ of illness into an empathic reflection on and understanding of a patient’s situation. Narrative medicine programmes are now a hallmark of much medical education, especially in the USA, as it becomes more commonly appreciated that doctors who read narratives of illness attentively and reflectively can deepen their knowledge of what it means to undergo an illness. By engaging with a patient’s linguistic articulation of illness, and foregrounding a language with which the patient can connect, medics participate in a more patientcentred, even humanistic, form of clinical care for, as Josie Billington has stated, ‘[c]aring for the patient’s story is not a peripheral task but constitutes the very point of medicine’.
Conclusion Illness narratives constitute an important medium for patients to reflect on the words that best capture their experience, and in the process to
Broyard, p. . Shanahan, p. . Rita Charon, Narrative Medicine: Honoring the Stories of Illness (Oxford and New York: Oxford University Press, ), p. . Josie Billington, Is Literature Healthy? (Oxford: Oxford University Press, ), p. .
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understand their situation in ways that privilege subjective creativity over technical knowledge. In so doing, the patient forges a language of illness – ‘a primary personal data’ – that is divested of the jargon of medicine. And yet, it is precisely the fact that language allows for the translation of experience into communicable meaning that pathographies are of interest – and use – to medics. But for the value of pathographies to be fully realized, new forms of literary engagement are required. Firstly, as Billington notes, medical practitioners can only appreciate the benefits of accounts of illness if they have a ‘willingness to enter the inchoate and indeterminate areas of individual experience where technical efficiency and skill alone are out of place or redundant’. Equally, however, a shift in perspective is required of literary critics who, as Ann Jurecic points out, are not always trained to trust ‘ordinary motives for reading and writing’ or that narrative can ‘provide access to the experience of another person’. Illness narratives, then, have not only offered effective possibilities for patients to translate their experiences into imaginative and even energizing accounts; they have also ‘shifted the boundaries of literary study’. By forging connections between illness, the body, and perception more generally, as well as between patients and wider communities – including medics – who desire to understand better what it means to be ill, pathography has galvanized literary production and engaged millions of new readers globally. It has done so precisely because, in the creative challenge to translate the human experience of illness, as patients, all of us must periodically engage in acts of transformation and reconfiguration as we negotiate the ‘fall’ of language.
Billington, p. . Billington, p. . Ann Jurecic, Illness as Narrative (Pittsburgh: University of Pittsburgh Press, ), p. . Jurecic, p. .
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Translating Chronic Pain and the Ethics of Reading in the Personal Essay Marie Allitt
In his comprehensive study of The Culture of Pain (), David B. Morris posits a dichotomy in diagnostic understandings of pain: meaning and meaninglessness. This frames the key difference in the clinical perceptions of pain, where acute pain has meaning, while chronic pain is meaningless. This binary is correspondent with the usefulness of pain: of course pain has a function, it warns us when something is wrong, when a fall has caused a bruise or a break, or signals underlying disease or illness. Pain tells a story, but chronic pain poses a puzzle – perhaps occurring from a long-healed injury, or even suddenly appearing with unknown causes. There is also an inherent paradox to chronic pain experiences: to experience a pain and be told it is nothing to worry about, that nothing is wrong with your body, and therefore meaningless, can be a relief. However, to be told that your pain is meaningless is to be told it is not real. This sense of meaninglessness perhaps explains our difficulty in voicing the experience of pain, and why specifically chronic pain is not an obvious literary subject and its expression a source of debate. Although we might see characters grappling with the ongoing pains of an amputation, the residual pains of a war wound, or pain spasms of terminal cancer, chronic pain is rarely placed centre stage. Life writing, and autobiographical works of illness and injury, however, expose an aspect of living with chronic pain that readers might
David. B. Morris, The Culture of Pain (Berkeley and Los Angeles: University of California Press, ), p. . Although chronic pain has not always received much literary critical attention, there is emerging research in part due to the growth of disability studies. For example, Michael D. Snediker, Contingent Figure: Chronic Pain and Queer Embodiment (Minneapolis and London: University of Minnesota Press, ). For more on literary and cultural histories of pain see: Joanna Bourke, The Story of Pain (Oxford: Oxford University Press, ); Martha Stoddard Holmes, Fictions of Affliction: Physical Disability in Victorian Literature (Ann Arbor: University of Michigan Press, ); Pain and Emotion in Modern History, ed. by Rob Boddice (London: Palgrave Macmillan, ); Sander Gilman, ‘Seeing Bodies in Pain’, in Health Humanities Reader, ed. by Therese Jones, Delese Wear, and Lester D. Friedman (New Brunswick and London: Rutgers University Press, ), pp. –.
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Translating Chronic Pain and the Ethics of Reading
otherwise never see. Perhaps we need the ‘I’ of the personal narrative in order to truly see the impact of chronic pain, and be exposed to creative expressions of painful experience. Contemporary narratives of chronic pain are framed by the unexplained. Mysterious, unresolved, and unacknowledged pain, often accompanied by a struggle for a medical practitioner to take the pain seriously, is a dominating feature of contemporary pain discourse. While chronic pain is not always mysterious or untreatable, it does seem that an air of antagonism and suspicion always accompanies expressions of pain. This puts a greater level of importance on the articulation and expression of pain, and compels the person-in-pain to self-advocate and find power in words. Recent illness narratives and memoirs of chronic pain can be seen to develop a shared language with which to articulate their physical sensations. Intertextuality, in particular, directly shapes the social aspect of the shared language of pain, while also highlighting the limits to such collectives. Eula Biss’s creative essay, ‘The Pain Scale’ () has become a significant textual touchstone, where she demonstrates the problems with translating pain to a ubiquitous scale, to numbers which evade and bypass the full weight of experience. In much the same way that Virginia Woolf’s ‘On Being Ill’ or Susan Sontag’s Illness as Metaphor have become key reference points in the discussion of modern illness, Biss’s essay has provided a key to unlocking the discussion of pain, and generated networks of pain expression. The urge for a shared language of pain, where recognition might be found in the words of others, and taken up in their own personal discourse of pain, binds the illness narratives I discuss in this chapter. Focusing on Biss’s ‘The Pain Scale’ and further essayistic examples from Sonya Huber’s Pain Woman Takes Your Keys and Other Lessons from a Nervous System (), Sinéad Gleeson’s Constellations (), Lisa Olstein’s Pain Studies (), Molly McCully Brown’s Places I’ve Taken My Body (), Amy Berkowitz’s Tender Points (), and Anne Boyer’s The Undying (), I explore the attempts at expressing pain, as well as the meta-commentary on the difficulty of expression. Significantly, these are all examples of personal or lyric essays, which pertain to the growing form of the illness narrative, or pathography: Ann Jurecic has encouraged more sustained attention to this form, and demonstrated how it uniquely lends itself to the expression of illness experience. I will go on to show that form, and particularly the essay
Ann Jurecic, ‘The Illness Essay’, Life Writing, , (), –. I discuss illness essays further in Marie Allitt, ‘Medical Humanities’, in Contemporary Literature and the Body: a Critical Introduction, ed. by Alice Hall (London: Bloomsbury, ), pp. –.
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form, is a productive context for the expression of pain, and influences how expressions are read and interpreted by different readers. Most discussions of pain in recent decades have castigated Elaine Scarry’s prominent claim that ‘[p]hysical pain does not simply resist language but actively destroys it’. Although Scarry’s assertion seems to align with Woolf’s claim about the ‘poverty of language’ when it comes to illness and pain, this does not explain how and why we still persist in talking about it. Importantly, Jurecic has pointed out that much of the criticism directed at Scarry’s words has focused only on her early argument, which centres on the extreme pain of torture, and overlooked her later claim that there is potential for creativity, especially for something like chronic pain. Martha Stoddard Holmes has also pointed out this error in pain theory, reminding us, and indeed encouraging us, to re-evaluate not only how we interpret Scarry’s landmark work, but also how we address the problem of pain’s language. The pervasive idea that pain cannot be put into words shapes how pain is experienced, how medicine reacts to it, and how it is expressed. Illness narratives have often been read for their closeness to real events, scrutinized for reliability, rather than understood as playing with symbolism and representation. Preoccupying discussions of the ethics of life writing concern questions of veracity, which have come to overshadow other ethical concerns of reading life writing. Evolving models of the pathography, such as autofiction, fragments, prose-poetry, collage, manifestos, and lyric essays, often play with genre and form, hybridity and fluidity, stretching the language and imagery of pain and suffering, and in so doing refute questions of accuracy or authenticity in favour of playing with representation. Shifts in textual style, then, require an audience that is not reading for fact, truth, and authenticity, but a reader who is attuned to the lyrical, the impressionistic, and the inconsistent rhythms of bodies in pain. Those writing their pain are burdened by the presumptions that their pain is not real, or not taken seriously, and that even if it were, it
Elaine Scarry, The Body in Pain (New York: Oxford University Press, ), p. . Virginia Woolf, On Being Ill with Notes from Sick Rooms (; Middletown: Paris Press, ). Ann Jurecic, Illness as Narrative (Pittsburgh: University of Pittsburgh Press, ), p. . Martha Stoddard Holmes and Tom Chambers, ‘Thinking through Pain’, Literature and Medicine, , (), – (p. ). One of the big preoccupations in the ethics of life writing is accuracy and authenticity, as demonstrated in the introduction to G. Thomas Couser, Vulnerable Subjects: Ethics and Life Writing (Ithaca: Cornell University Press, ). See Allitt.
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Translating Chronic Pain and the Ethics of Reading
would be impossible to convey. It falls to readers, then, to shrug off their positions of suspicion, and engage with a more ethical reading. For Alphonse Daudet, in his s account of what is today termed ‘neurosyphillis’, ‘[p]ain is always new to the sufferer, but loses its originality for those around him. Everyone will get used to it except me.’ In her discussion on regarding the pain of others, Jurecic reads in this, Daudet’s suggestion ‘that personal stories of pain, even those as inventive as his own, become flattened, generalized, and reduced to banalities by listeners’. It is an unfair inevitability that those without pain will cease to hear the force of the distress, and likely become inured to its expression. There is a responsibility for the listener and reader to fully hear the intensity of the pain, and not let it wash over them. The expressions of pain must not become flattened and reduced to the banal or the unimportant. In the reworking of pain’s language there is the attempt to refresh and renew, but this must be accompanied by a kind of reading that is attentive and receptive to the experimentation with expression. We see such reworking in the essay, where its features of digression, contradiction, fragmentation, and incompleteness seem to offer something especially distinct to expressing the emergent experiences of illness, but this requires a reader to engage in a kind of ethical reading which is mindful of the attempt, and not trying to find a conclusion. Criticism’s attachment to the claim of the insufficiency of language demonstrates that many readers want a depiction as correlative to the clinical as possible, and that while creative responses to pain are welcomed, they will never be considered sufficient. What I want to show here is that such pain narratives, especially enabled by the essay form, foreground the trial of expression, and it is the very experimentation with language that is crucial to the expression of pain. Perhaps the problem is not whether a language for pain can be found but, as Jurecic suggests, ‘rather how to make readers receptive to stories of pain . . . who will listen and what will they hear?’ Does the continual return to the ‘pain destroys language’ debate inhibit our hearing (and reading) of the pain depictions? Is the reader really listening, or trying to impose answers? An ethics of reading often suggests readers come away with an altered or informed moral position, but here I suggest that there is an ethics of reading in how
Alphonse Daudet, In the Land of Pain, ed. and trans. by Julian Barnes (New York: Borzoi/Knopf, ), p. . Jurecic, Illness as Narrative, p. . Jurecic, Illness as Narrative, p. . J. Hillis Miller, The Ethics of Reading (New York: Columbia University Press, ).
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the reader attends to the textual depictions of pain, which involves attentive reading and listening. There is a prevailing risk that ‘the ubiquitous representations of pain can dull the sensations of spectators to its reality’, so language must work in more powerful ways.
Expressing Pain According to Biss, ‘[t]he problem of pain is that I cannot feel my father’s, and he cannot feel mine. This, I suppose, is also the essential mercy of pain.’ To be able to communicate the feeling of pain can be a necessity, but amidst its untranslatability is at least a saving grace that others cannot know the fierceness of it. While there are substantial arguments that push against the untranslatability of pain thesis, the self-awareness of such burdens frame many of the pain narratives seen here, with many even employing ‘translation’ as a model of articulation. There are times when the pain needs to be put into words, and interacting with those in a similar position might offer some relief. Sonya Huber explains that when she is experiencing intense pain, she ‘take[s] to Twitter and texting, to message boards and groups that save my sanity. I find myself caught in a web with other women’s bodies and minds. We’ve been fused together, thankfully joined via the Internet, where we pool our symptoms and start advocacy groups and share diagnosis and treatment strategies.’ Sharing pains becomes both a necessity and a lifeline: connection with others is a reminder that they are not alone, that their pain is heard by others, witnessed and believed, even when medicine fails to acknowledge its hurt. Tiredness and fatigue soon set in when pain hits, and the task of continually trying to explain and evidence the intensity accelerates exhaustion. Molly McCully Brown, whose essay collection details her experiences with cerebral palsy, demonstrates that there are times where it is too much to keep on having to explain: Pain makes me tired. My body needs to rest, but it’s more than that. I’m exhausted by feigning comfort, and I don’t want to translate what’s going on inside me, even for my friends. They’re sorry when I’m hurting but, for them, the act of rising from the couch and standing is effortless and instant.
Rita Charon, ‘How to Listen to the Talk of Pain’, Encountering Pain: Hearing, Seeing, Speaking, ed. by Deborah Padfield and Joanna M. Zakrzewska (London: UCL Press, ), pp. – (p. ). Eula Biss, ‘The Pain Scale’, Seneca Review, , (), – (p. ). Sonya Huber, Pain Woman Takes Your Keys and Other Essays from a Nervous System (Lincoln and London: University of Nebraska Press, ), p. .
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Translating Chronic Pain and the Ethics of Reading
The only thing that explaining my body will do is widen the gulf between us.
It is hard to describe pain to anyone, but especially those who are not in a similar position. In an ideal world, no one would have to explain or evidence unless they wanted to. As Lisa Olstein explains, ‘[w]hatever pain you’re in is the worst kind, and when it’s bad, it’s untranslatable, but that doesn’t keep you from having to try’. It is a full-time job to articulate and commentate on the current state of your body – there is the imperative to explain it in clinical contexts, and inevitably some kind of explanation to friends and family – but do we put too much pressure on bodies in pain to keep on telling, and to keep on showing? Olstein ambiguously tells us that the worst of pain ‘doesn’t keep you from having to try’, but the ‘having’ is unclear: is the drive an external or internal force? Do others keep making her try, or does her body tell her she must keep on trying? The struggle comes not just from a lack of energy or strength, but the lack of the right words. Anne Boyer explains that ‘[a] body in mysterious discomfort exposes itself to medicine hoping to meet a vocabulary with which to speak of suffering in return. If that suffering does not meet sufficient language, those who endure that suffering must come together to invent it.’ It falls to the individuals in pain to find others who might understand, who do not require you to translate, but are open to hearing your attempts at articulation, and within these necessary communities, there is the possibility of inventing that sufficient language. Crucially, this shared language and community of reference points are not static, but continually evolving. Pain and its difficulty in expression is nothing new, but arguably, chronic pain is a modern phenomenon, worsening, ironically, in parallel with advances in medicine. Medical advances from the mid-nineteenth century onwards, especially borne out of large-scale modern conflict, reduced fatality from accident and injury, and in saving lives, developed a greater scrutiny of the body on a daily basis. Greater survival from amputations from war saw growing instances of phantom limb pain, which, already entangled with an aura of mystery, demonstrated the complexity of pain signals. With such advances there have been extensive
Molly McCully Brown, Places I’ve Taken My Body (; New York and London: Faber & Faber, ), p. . Lisa Olstein, Pain Studies (New York: Bellevue Literary Press, ), p. . Olstein, p. . Boyer, p. . Rob Boddice, Pain: A Very Short Introduction (Oxford: Oxford University Press, ), p. . While the term ‘phantom limb’ was first used by Silas Weir Mitchell, and more commonly associated with the American Civil War, evidence does suggest that the phenomenon has been
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developments in pain relief from anaesthetics to painkillers, but even with greater recourse to using analgesics, these have not always been available (with stretched supplies during crises) or have, to certain practitioners, been seen to screen symptoms and inhibit diagnoses. The complexity and illogicalness of pain signals have become a tortured ground for both medical practitioners and patients, where pain does not perform as it might once have been expected to. Severe pain is not always a scream and cry: ‘It is not a pleasant trait, but we sometimes feel suspicious of people who say they are in pain but who do not groan or writhe or pound the floor.’ Pain knowledge is insubstantial, and despite the development of dedicated pain clinics from the s onwards, bodies continue to baffle science and medical practice. Attempts to visualize and measure pain have increased since the midtwentieth century, with the development of various pain charts, descriptive terms, and visual-linguistic scales, as a means of taxonomizing types of pain. However, bodies have continually thwarted such aims, and medicine has had to grapple with the importance and utility of subjective reports of pain. There are two particular types of pain scale I go on to discuss here: the numerical scale where patients rate their pain from one to ten, and the McGill Pain Index, developed by Ron Melzack in , which offers groups of descriptive words which patients select to describe their pain sensation. While there are difficulties at both the personal and the clinical level, both spheres attempt to invent the language needed to convey their pain, even if it only comes close to being sufficient.
Rewording Pain In Tender Points, Amy Berkowitz likens her experience of fibromyalgia to the story of the Sphinx, pushing against the genre of the riddle in the search for control, agency, and answers: ‘I don’t like riddles. And yet here I am, obsessed with solving a riddle of my own, the riddle of my body: Why, exactly, am I constantly in pain?’ She further explains that ‘[w]hile
noted earlier, with examples from the medieval period: Alastair Minnis, Phantom Pains and Prosthetic Narratives (Cambridge: Cambridge University Press, ). Joanna Bourke, The Story of Pain (Oxford: Oxford University Press, ), pp. –. Morris, p. . See Nicole Miglio and Jessica Stanier, ‘Beyond Pain Scales: A Critical Phenomenology of the Expression of Pain’, Frontiers in Pain Research, () . Amy Berkowitz, Tender Points (; New York: Nightboat Books, ), p. .
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Translating Chronic Pain and the Ethics of Reading
a puzzle can be solved with just one or two missing pieces, pain is much more complicated, and talking about pain – especially chronic pain – as if it has an easy answer can be irresponsibly deceptive’. She spells out that there is no simple solution to the pain, and even thorough diagnosis does not mean a pain-free life. Berkowitz’s comments acknowledge some of the dangers that presuming a definitive answer has for both medicine and those in pain. Characteristic of the intertextuality of contemporary illness narratives, she engages with Morris’s suggestion for a shift in language from pain as a puzzle, to pain as a mystery. In part, this is to counter the language of conquest that he identifies in pain research – and in some respects responds to Sontag’s warning about the militarization of medical language. However, this is also to shift the search for answers to be less about topdown knowledge and victory, and more about a shared answer that clarifies but does not pretend to be able to explain everything. Shifting to the language of ‘mystery’ is not comfortable, but it can help us ‘respect [pain’s] complexity and recognize the alienating experience of living in pain’. This rewording not only reminds us that the language used about pain shapes how it is approached, but recognizes that multiplicity is a much more realistic approach to seeking answers. This shift from puzzle to mystery can explain the kinds of pain memoirs emerging in the twenty-first century. They are not seeking to capture the single best articulation of pain, nor are they trying to provide solutions, instead they are generating language that might be further melded into the articulation of one’s bodily experiences. In her analysis of Biss’s essay, Susannah B. Mintz argues that ‘pain is not simply attendant upon other experiences or conditions; instead, pain is her source, her vocabulary, her point. There is no writing the end of pain, because pain does not end; there is no conclusive explanation for her pain, and thus no coherent narrative in the essay.’ We see this across multiple texts – those that do and do not engage with Biss’s essay – where no end or resolution is trying to be met, because there is no end in sight. This is an active push against medical discourse that is always seeking cure and recovery and trying to put the final pieces of the puzzle in place. In his significant study of illness narratives, The Wounded Storyteller (), Arthur Frank offers the concept of ‘narrative surrender’, where ‘the
Berkowitz, p. . Morris, pp. –. Berkowitz, p. . Susannah B. Mintz, Hurt and Pain: Literature and the Suffering Body (London: Bloomsbury, ), p. .
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ill person not only agrees to follow physical regimes that are prescribed; she also agrees, tacitly but with no less implication, to tell her story in medical terms’. Not only is it the physician who narrates, but the body is reduced to a clinical object and shrouded in medical jargon. Illness narratives emerge to counter this and reclaim one’s own voice in the discourse of their own body. We can see, however, how medical language might be usefully co-opted in order to break through the jargon, and find productive articulations of pain, which requires those who suffer to come together to invent and reinvent the vocabulary of pain. Alice Hattrick’s Ill Feelings () offers the idea of ‘subterfuge’ when it comes to medical language: terms taken from medicine, and reworked and reused in a form of resistance and reclamation. Where medical jargon has served to objectify, dissociate, and undermine pain sufferers, we can see the attempt to reclaim and renew such language with the borrowing of pathologized terms, irony, or inversion, of which ‘the pain scale’ is an example.
Literary Pain Scales The pain scale is a notable example of co-opting the clinical discourse. Given that they are a necessary stage in clinical encounters, most life narratives of chronic pain will in some way engage with the pain scale. In this section, I show examples of what Jurecic has come to call a ‘literary pain scale’, and demonstrate how the literal language of both the numerical – pain scale and the McGill Pain Index have been rewritten and creatively reconceived. The pain scale is a source of frustration; one that recurs and becomes a specific step in any clinical interactions around pain. The numbers become meaningless, which is precisely what drives Biss’s lyrical essay – ‘[e]very time I go to the doctor and every time I visit the physical therapist, I am asked to rate my pain on a scale from zero to ten’ – where her frustration in the insubstantiality of the pain scale and its recurrent use contributes to her disassembly of the scale. The numbers are supposed to counter the invisibility, but leave a further void: There is no evidence of pain on my body. No marks. No swelling. No terrible tumor. The X-Rays revealed nothing. Two MRIs of my brain
Arthur W. Frank, The Wounded Storyteller: Body, Illness, and Ethics (; Chicago: The University of Chicago Press, ), p. . Alice Hattrick, Ill Feelings (London: Fitzcarraldo Editions, ), p. . Ann Jurecic, ‘A Literary Pain Scale’, The Lancet, , (), . Biss, p. .
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Translating Chronic Pain and the Ethics of Reading
and spine revealed nothing. Nothing was infected and festering, as I had suspected and feared. There was no ghastly huge white cloud on the film. There was nothing to illustrate my pain except a number, which I was told to choose from between zero and ten. My proof.
Especially because there is no trace of an injury or cause recognized by tests, the numbers are attempts at replacing the void, but result in further confusion and frustration. Split into ten sections, Biss’s essay offers snapshots of moments and memories relating to pain and expression. She aligns the pain scale with other numerical and descriptive scales, including the Beaufort Scale (wind), the Fahrenheit, Celsius, and Kelvin scales, and Dante’s seven circles of hell. Biss demonstrates both the meaninglessness of reducing a bodily experience to a number and the arbitrariness of ordering language when it will be reinterpreted. One of the problems is that the scale presumes that everyone starts from zero, and that everyone’s zero is the same. In order for Biss to genuinely assess her pain levels, she ‘need[s] a zero. A scale of any sort needs fixed points.’ Even though she alone can be an authority of her body, her perception and knowledge is challenged: The sensations of my own body may be the only subject on which I am qualified to claim expertise. Sad and terrible, then, how little I know. ‘How do you feel?’ the doctor asks, and I cannot answer. Not accurately. ‘Does this hurt?’ he asks. Again, I’m not sure. ‘Do you have more or less pain than the last time I saw you?’ Hard to say. I begin to lie to protect my reputation. I try to act certain.
Biss is not alone in this experience; Berkowitz cannot ‘remember how it feels not to be in pain. At the doctor’s office, pain scales are impossible because I lost my zero. I choose a number because I’m supposed to choose a number’, while Huber ‘always get[s] confused by this instrument, partly because I don’t know what each level means’. Olstein, who, like Huber, directly discusses Biss’s essay, explains that ‘[b]efore coming across the essay, I’d spent years hating the standard numerical scale . . . hating myself when confronted by it, ricocheting as I did between indignation, shame, and confusion. So finding the essay was a kind of reprieve, the validation of a frustration that had long confounded me.’ The recognition of someone else in a similar state of frustration and intense discomfort
Biss, p. . Olstein, p. .
Biss, p. .
Biss, p. .
Berkowitz, p. .
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Huber, p. .
is a reminder that there are millions of people in chronic pain, and despite the loneliness, you are not alone. Biss’s essay provides some language, and the beginnings of an image, which Olstein borrows and extends. It is a salve and inspiration: an opportunity to transliterate into her own words, while also being part of a community. Boyer offers a similar critique, equally frustrated by the imperative to ‘Rate your pain on a scale of one to ten.’ She tries to answer, ‘but the correct answer is always anumerical. Sensation is the enemy of quantification. There is no machine, yet, to which a nervous system can submit sensation to be transformed into a sufficiently descriptive measurement.’ Later, she turns to the poetry of Emily Dickinson as a way to assist in finding the words for pain: Every time I was asked to give pain a number, my friends and I made plans to sneak pamphlets with alternate vocabularies of pain into the waiting rooms. These guides to the new language of pain would consist mostly of the poems of Emily Dickinson . . . After Great Pain – A Formal Feeling comes x No man can compass despair x It ceased to hurt me x There is a pain so utter x Pain has an Element of Blank x From Blank to Blank x Pain has but one acquaintance and that is death
The sequence of numbers are the numbered poetry rather than the hollow to . Boyer suggests that the descriptors for each pain might be summarized by the first line of one of Dickinson’s poems, which taken together create an additional narrative, or even meta-narrative on the sequences of pain. A poetic sequence of pain is similarly offered in Constellations, where Sinéad Gleeson plays on the genre of the pain scale by turning the McGill Pain Index’s words into poetry to counter the insufficiency of its words. The patient is free to select multiple words, but pain cannot be reduced to one lexical bracket. It is difficult to explain a specific pain to someone who has never experienced it, or to someone whose life has been largely devoid of pain. Medical practitioners created the list and chose the descriptors. The words do not come from the person experiencing the pain; the words belong to the doctor, not the sufferer. This is an attempt at reclamation.
Boyer, p. . Italics in original.
Boyer, p. .
Boyer, p. .
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Translating Chronic Pain and the Ethics of Reading
How many times have you been in pain? Did you have all the words you needed to tell the story of it? What is the vocabulary of pain?
Gleeson illustrates how the use of specified terminology and descriptors of pain is another instance of narrative surrender, where ‘the words belong to the doctor, not the sufferer’. In ‘an attempt at reclamation’, Gleeson then offers a series of short poems each entitled and triggered by a series of the words. However, those words rarely appear in the poem. Instead, the poems show the impacts of, for example, how pain in her wrist stops her from picking up her baby son. Gleeson shows that those sensations – ‘Flickering, Pulsing, Quivering, Throbbing, Beating, Pounding’ or ‘Hot, Burning, Scalding, Searing’ – are just the beginning. These words offer a minuscule starting point of access to the experience of pain, but it is only a beginning. There are so many more words, an entire narrative, and even rejections of narrative order, behind those selected terms. We might consider Gleeson’s recreation of the descriptive pain terms a kind of ‘subterfuge’, stealing words from medicine to expand the language of pain.
Weathering the Storm Clinical terminology is also deconstructed and reinvented when put into dialogue with other scientific discourses. Biss’s essay places the pain scale alongside the Beaufort Scale, which measures wind: ‘It took sailors more than two hundred years to develop a standardized numerical scale for the measure of wind. The result, the Beaufort scale, provides twelve categories for everything from “Calm” to “Hurricane”. The scale offers not just a number, but a term for the wind, a range of speed, and a brief description.’ The analogy, for Biss, has more usefulness than a numerical value, because of its descriptive category: ‘A force wind on the Beaufort scale, for example, is a “Light Breeze” moving between four and seven miles per hour. On land, it is specified as “wind felt on face; leaves rustle; ordinary vanes moved by wind”’, whereas ‘[t]he description of hurricane force winds . . . is simply, “devastation occurs”’, moving from discomfort to intolerable pain. Similarly, Olstein finds use not in the numbers, but the descriptions which ‘read as shorthand, really, for exquisitely tuned, twinned descriptions of the physical world by land and by sea’. But, while Biss focuses on
Sinéad Gleeson, Constellations (London: Picador, ), p. . Biss, pp. , .
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Biss, p. .
the ‘on-land descriptions’, Olstein ‘find[s] it’s what happens at sea that reads eerily like a mounting migraine’. In a found-poem crescendo of pain, Olstein paints a picture of a wave of pain that moves from ‘[s]ea surface smooth and mirror-like/Scaly ripples, no foam crests’ gradually building to ‘[l]arge wavelets, crests begin to break, scattered whitecaps’, and up to ‘[e]xceptionally high waves, foam patches cover sea, visibility more reduced’. Where Biss invokes the Beaufort Wind Scale as a figurative comparative to the pain scale, Huber turns to the weather and climate in more literal terms. Huber’s rheumatoid arthritis means that her body is directly affected by air pressure, and so she becomes increasingly sensitive to changes in the weather. In two of her essays, ‘The Lava Lamp of Pain’ and ‘In the Grip of the Sky’, Huber illustrates the effects on her body: The sky has its way with me. As clouds lower their shoulders against the horizon, a warm front’s humid body slides along my skin, lifting the hem of my dress to curl around my waist and stretch along my spine. Closer still, the atmosphere enters me soundlessly. Barometric pressure squeezes my joints, each a tiny fishbowl of synovial fluid that cushions the space where two bones pivot and swing.
She steadily becomes a barometer, attentive to the shifts in air pressure, listening as ‘[t]he rhythm and shifting whorls scrawl inside my flesh and bone in a patterned grammar I can almost pretend to decode. I have decided to listen to the air.’ She turns to the chemist Luke Howard’s taxonomy of clouds, whose identification of patterns helped reveal key facets of meteorology: ‘He had recorded how one weather event led into another and how to see the patterns. He called them cirrus. Cumulus. Stratus. He then broke them into subtypes that might be combined to create complete vocabulary.’ She identifies with the process and character of the chemist, whose forays into meteorology were amateur yet vital, much like her own expertise is improvised and learned by being. Huber uses Howard’s discoveries, descriptions, and naming as an analogue to her own methods of discovery – where she must map pain and pressure, ‘trying to see the logic in the swells and surges’. In this somatic forecasting, we are reminded of the importance of patterns, shapes, and sequences.
Olstein, p. . Huber, p. .
Olstein, pp. –. Huber, p. .
Huber, p. .
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Huber, p. .
Translating Chronic Pain and the Ethics of Reading
Forming Ethical Reading Philosophies of the ethics of reading are often predicated on the power of imagination to invoke a moral response in the reader, such as generating empathy or a greater awareness for the lives of others. Such concepts are a stronghold in medical humanities – particularly in arguments that medical practitioners should engage with the humanities in order to be a better doctor by developing a greater humanism. While this is a popular perspective, the desired ethical transformation is yet to be realized, but areas such as narrative medicine have worked hard to embed the skills of narrative within clinical methodologies, with its emphasis on narrative competence and clinical imagination. While this provides a certain degree of literary-critical skills, such as close reading, it can overly privilege narrative. As Angela Woods argues, expressions of the lived experience would benefit from a de-privileging of narrative, with recognition ‘that different cultures (including familial, institutional and professional cultures) will tell and find meaningful different kinds of stories, but also, more fundamentally, that the attachment to and valorisation of narrativity is not universally shared’. Part of the problem is in the different ways ‘narrative’ is used and defined outside of literary studies, which often ‘risks mistaking a specific form of primarily linguistic expression for the master-trope of subjective experience’ and results in presumptions that readers can gain unmediated access to the reality of the lived experience. There are limits to narrative and its primacy as expression’s aspiration should be questioned, especially the pervading idea of its inherent goodness. Any critique of medical life writing must also be receptive to challenges around what narrative means to different people, and how there can also be a great deal of expression in the non-narrative. ‘[W]hen the doctors do not respond with their full professional and personal resources, they commit an ethical failure that is intimately intertwined with their failure to listen’, which might be resolved by what Jurecic terms ‘attentive listening’. This approach comes close to what Sara Wasson suggests is ‘a complementary critical stance’ which helps ‘to avoid marginalising vulnerable voices’:
For example: Martha Nussbaum, Upheavals of Thought: The Intelligence of Emotions (Cambridge: Cambridge University Press, ); Richard Rorty, Contingency, Irony, and Solidarity (Cambridge: Cambridge University Press, ). Jurecic, Illness as Narrative, p. . Angela Woods, ‘The Limits of Narrative: Provocations for the Medical Humanities’, BMJ Medical Humanities, , (), – (p. ). Woods, p. . Woods, p. . Jurecic, Illness as Narrative, p. .
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this is an approach which is ‘more attuned to the social context for chronic pain suffering and the complex temporality of the experience of structural marginalisation’. Attentive listening requires not only a willingness to hear the pain, but also the willingness to believe it. All of the texts I have discussed here are examples of creative nonfiction, and share features of lyrical essays. This emerging form is providing a new mode of articulation, especially fruitful when it comes to experiences of suffering, illness, or pain. In Biss’s essay, and texts that have responded to it, we see how clinical forms and patterns – the scale – are challenged along with the language they contain. The problem with the scale is not only its provisory application of meaning, but that it continues to assume experience is linear and coherent. Lyrical essays, however, enable process and ‘[i]nstead of telling the straight story of memoir, they say: This is the story of how my mind moves.’ The essay seems an exceptionally effective form for the expression of pain. Pain finds its articulation (which is never just one thing, but always on its way to translation and transliteration) in a form that permits meander, discovery, and experimentation. The lyric essay is included within the broader term of creative non-fiction, which Margot Singer and Nicole Walker usefully summarize, explaining that: As readers, we tend to take realistic narrative for granted. We treat as ‘natural’ the linear chronology of story, the way time is dilated or compressed, the artifice of dialogue . . . the highly selective filtering and reordering of the infinite details of the world. But rather than creating a transparent window onto reality, unconventional nonfiction tends to highlight the slipperiness of representation. It raises fundamental questions about the nature of memory and storytelling, ‘reality’ and ‘truth’.
These texts, as examples of ‘unconventional nonfiction’, challenge not only discourse but also form, a key feature of modern pathographies, which do not seek to offer a complete narrative, but signal that our bodies are susceptible to change, to chronicity of pains, and we are always in the process of understanding. As Mintz suggests, ‘[p]erhaps what matters to the memoirist of pain . . . is not so much the kind of credibility sought by a
Sara Wasson, ‘Before Narrative: Episodic Reading and Representations of Chronic Pain’, BMJ Medical Humanities, , (), – (p. ). Leslie Jamison, ‘What Should an Essay Do?’, The New Republic, July . Italics in original
[accessed July ]. Mintz, p. . Margot Singer and Nicole Walker, ‘Introduction’, in Bending Genre: Essays on Creative Nonfiction, ed. by Margot Singer and Nicole Walker (New York: Bloomsbury, ), pp. – (p. ).
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Translating Chronic Pain and the Ethics of Reading
traditional autobiographer or a patient, but the freedom to recall and/or recreate a truthfulness about pain unbound by strict generic parameters’. These pain narratives do not adhere to the traditional autobiography, or even the early pathographies first identified by Anne Hunsaker Hawkins; contemporary stories of pain (as well as illness, distress, and suffering) are exploring the creative possibilities for letting the body speak. The essay and essayism are ‘defined by contingency and trying things out digressively, following this or that forking path, feeling around life without a specific ambition: not for discovery’s sake, not for conquest’s sake, not for proof’s sake, but simply for the sake of trying’. Although there is a definition, it is not a strict set of formal features: its formal parameters challenge and continue to push against the possibility of expression. In The Undying, Boyer reflects on the risks for how personal narratives are received: I hate to accept, but do, that cancer’s near-criminal myth of singularity means any work about it always resembles testimony. It will be judged by its veracity or its utility or its depth of feeling but rarely its form, which is its motor and its fury, which is a record of the motions of a struggle to know, if not the truth, then the weft of all competing lies.
While Boyer alludes to the anxiety over how illness narratives can be taken too much at face value, with ‘its veracity or its utility’ given too much attention, she also hints at problems with labelling. There are illness narratives which claim, explicitly or implicitly, that they are a testimony of what it is really like, but to presume all narratives fit this role is problematic. How a text is labelled and described is important if that label presumes veracity: a testimony is doing different work to a piece of creative nonfiction. By foregrounding form, Boyer is not being precious about her work’s literary credentials; instead, she is highlighting formal qualities as a reminder that she is not the authority, and she is only beginning to know. She seeks to emphasize that such records of experience are on the way towards an understanding, in the process of being experienced, and not always able to be fully understood or ever able to become narrative. She tells us that ‘the weight of these events remains too heavy for their telling’. It is possible that Boyer does not mean literary form, but forming: beginning to
Mintz, p. . Christy Wampole, ‘The Essayification of Everything’, The New York Times, May [accessed July ]. Boyer, p. . Boyer, p. .
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grow, to understand, to remember, to be, again. She struggles to write, but she compiles the feelings and impressions into something that might be reparative, and through which she might discover. To be sick is to grapple with ‘a weft of competing lies’: that medicine can help; that caregivers care; that you will feel better; that people will stick by you. The body in pain, too, is a liar: lying to others, lying to the self. The lyric essay can position those lies alongside one another, to be questioned and interrogated, hopefully leading to revelations of a personal truth. This chapter has shown that the language of pain is far from ‘destroyed’. While expression has to work harder, language pushed, and form challenged, the onus to understand pain does not lie solely on the sufferer. The listener needs to employ a kind of reading that is ethically receptive to the lived reality of pain: believing the pain; acknowledging its existence even if it is not wholly understood; accepting its mystery, and acting to help and heal, but not mislead into thinking it can be fully resolved. Better listening (reading) is central to the ethical responsibility certain readers have for encountering such narratives of pain. As Daudet cautioned, there is a risk of expressions of pain being flattened, made banal, and divorced from their impact on the sufferer. The reader must listen attentively, recognizing the multiplicity of the pain, the complexity of its signals, accepting that it might not make sense, it might be contradictory, but there is pain nonetheless. Chronic pain is burdened, not only by the toll on the body, but also by its reputation as inexpressible and untreatable. There is a vulnerability in attempting to describe the pain, and a boldness in finding that language. Much of it is trial, attempt, and process and the ‘record of the motions of a struggle to know’ is precisely what the lyrical essay facilitates. This boldness is also bravery for countering the suspicion that is all too often brought to expressions of pain. Pain is shared with those in a similar state and textual touchstones help create a network and deepen a language that can be shared among a community of sufferers. As Boyer explained, if there is not the language, then you must invent it. Such invention can adopt and bend medical discourse and in acts of linguistic ‘subterfuge’ challenge medicine’s vocabulary for pain. It can unsettle what is understood by ‘burning’ or ‘stabbing’, question quantification, and introduce images of pressure and expansion, of crescendos and decelerations, which defy logic and paint a different picture of pain.
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Physician-Poets and Vitalist Theories of Life James Morland
In the opening to his autobiography, the physician-poet William Carlos Williams expresses his surprise at learning the origins of a medical term from poetry: ‘Only yesterday, reading Chapman’s The Iliad of Homer, did I realise for the first time that the derivation of the adjective venereal is from Venus! And I a physician practicing medicine for the past forty years. I was stunned!’ Noting the etymological links between medicine and poetry, Carlos Williams aligns himself with another physician-poet, John Keats and his sonnet, ‘On Looking into Chapman’s Homer’. Here, Carlos Williams connects his position of physician-poet to the long tradition of poetry and medicine being intimately linked through their shared language and histories. In a worn prescription pad, Carlos Williams noted that the ‘use of poetry is to vivify the singularly sterile fields of philosophy & science’. Poetry has a long history of being instrumental in helping to define and explore aspects of life within the medical body. To trace the history of the physician-poet and their explorations of life within the body, it is particularly fruitful to look at the long eighteenth century. ‘Physician-poet’ is an anachronistic term for the poets referenced in this chapter, as most are referenced as ‘both a poet and physician’ in various contemporaneous biographies. As Clark Lawlor and Ashleigh Blackwood have noted, the ‘habitual writing of poetry by doctors is a feature of the long eighteenth century’, and terms such as ‘physician-poet’, ‘doctor-poet’, or ‘poet-physician’ have come to define this poetry in contemporary
William Carlos Williams, The Autobiography of William Carlos Williams (New York: Random House, ), p. . Audrey Ruan, ‘William Carlos Williams: Physician Poet Scrawls Theory of Medical Humanities Throughout Prescription Pad’, British Medical Journal Blogs, October [accessed May ].
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scholarship. I have used the term ‘physician-poet’ in this chapter as it goes some way to encapsulating the pre-disciplinary ways these physicians used poetry as a means to demonstrate their understanding of issues being debated in the medical profession. Their poetry can also be read as equally medical and philosophical, and in parallel to the rise of philosophical poetry in the same period. Their poetic questioning of medical theory allowed an investigation into broader philosophical understandings of the self. Poetry was a means to question, and attempt to put into language, the non-mechanical elements of the human body that had been conjectured in both philosophical and medical theories, namely the vital flame of life. Throughout the eighteenth century, a well-respected man of medicine was also often a man of letters, writing prose and poetry. As Corinna Wagner notes, knowledge and ideas about the body and disease have long migrated between medicine and literature, and ‘scientific writing and poetry very often shared a common language’. As Wagner goes on to comment, the rhythms of poetry make it particularly suited to conveying the rhythms of the body. Produced in a period where medicine and literature had a cohesive relationship and influenced by classical models of philosophical and scientific poetry, these eighteenth-century physicianpoets represent how poetry and medicine have engaged with each other to reveal various aspects of inner and outer life. While Carlos Williams’s modernist poetry may initially seem a vast chronological distance from the poetry of the long eighteenth century, he was enamoured with John Keats when composing his early poetic work. Keats found poetic influence in medical and scientific philosophies, especially the mechanism-vitalism debates of the early s, and provides a Romantic predecessor of Carlos Williams’s theory of poetry’s vivifying qualities. As James Robert Allard notes in his study on Romantic poetry and medicine, ‘the means and ends of both medicine and poetry become most visible when we examine the figures who occupy the space at which these two discursive fields overlap’. This chapter will consider some of the ways physicians prior to Keats used poetry to explain the almost unexplainable quality of life that ran parallel to the consideration of the human body as a
Clark Lawlor and Ashleigh Blackwood, ‘Sleep and Stress Management in Enlightenment Literature and Poetry’, Interface Focus, , (), . Corinna Wagner, ‘Introduction’, in A Body of Work: An Anthology of Poetry and Medicine, ed. by Corinna Wagner and Andy Brown (London: Bloomsbury, ), pp. – (p. ). Wagner, p. . ‘Keats, during the years at medical school, was my God.’ Carlos Williams, Autobiography, p. . James Robert Allard, Romanticism, Medicine, and the Poet’s Body (Hampshire: Ashgate, ), p. .
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medical specimen. In a broad simplification, the eighteenth century saw a shift from mechanical theories of the body, seeing the body as a form of hydraulic machine, to vitalist theories that considered the body’s nervous system and its sensibility. Theodore Brown describes this shift as the ‘most striking feature of English physiology’ between and . Vitalism brought about ideas that life was generated in the body by some undefined, but non-mechanical, force. Vitalist thinking turned the focus towards the workings of the material body and what gives its collection of atoms ‘life’, though this was a focus of much physician poetry throughout the eighteenth century. Much current critical discourse on vitalism in the long eighteenth century has tended to focus on its emergence in the Romantic intersection of science, literature, and culture through the poetry of Keats and others, although this chronology is not as clear cut as a Romantic vitalism suddenly arriving fully formed. As Tristanne Connolly and Steve Clark note in their survey of literature and medicine in the eighteenth century, ‘Enlightenment medicine includes elements later seen as characteristic of Romanticism (such as vitalism).’ Following from Catherine Packham’s comments that considerations of eighteenth-century vitalism need to be understood in reference to the ‘intersecting eighteenthcentury enquiries in a range of discourses into the nature of life, matter and the human subject’, this chapter will focus on how the works of various physician-poets in the eighteenth century can be interpreted through this emergence of a vitalist language. Eighteenth-century physician-poets, inherently interested in life and death due to their medical profession, found themselves within a poetic space where the dividing line between living and non-living was always a decisive problem. This chapter will focus on physicians who wrote poetry in the eighteenth century, first drawing on the poems of Samuel Garth and Sir
Clark Lawlor provides an overview of the nuances of this shift between the first and second half of the eighteenth century in ‘Mere Flesh and Blood’ in Literature and Medicine: The Eighteenth Century, ed. by Clark Lawlor and Andrew Mangham (Cambridge: Cambridge University Press, ), pp. –. Theodore M. Brown, ‘From Mechanism to Vitalism in Eighteenth-Century English Physiology’, Journal of the History of Biology, , (Autumn, ), – (p. ). This is a point similarly argued by Catherine Packham in her study Eighteenth-Century Vitalism: Bodies, Culture, Politics (Basingstoke: Palgrave Macmillan, ), p. , who references key studies such as Sharon Ruston, Shelley and Vitality (Basingstoke: Palgrave Macmillan, ). For a further example connecting vitalism with Romanticism see Robert Mitchell, Experimental Life: Vitalism in Romantic Science and Literature (Baltimore: Johns Hopkins University Press, ). Tristanne Connolly and Steve Clark, ‘Introduction’, in Liberating Medicine, – (London: Pickering & Chatto, ), pp. – (p. ). Packham, p. .
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Richard Blackmore as early examples, before comparing them with their mid-century counterparts, namely John Arbuthnot’s Gnothi Seaton and John Armstrong’s The Art of Preserving Health. Vitalism within the eighteenth century can be understood in a wider context of how poetic form was used to explore different theories of life and the human body. Packham’s study sees vitalism in the eighteenth century ‘as a response to the inability of a mechanically oriented natural philosophy, inherited from the late seventeenth century, to understand the specificity of living systems, or the origins and nature of life, or the operation of the human body’. To define this vitalism, she suggests that ‘the language of vitality invokes contemporary theological and philosophical conceptions only to rework them; it plays with established senses of biology and physiology, of bodies, breath and life, but pushes those senses into new meaning’. This language of vitality, with its links to biology and physiology, has particular relevance to physician-poets who consistently question and rework medical theory in their poetic verse. The early- to mid-century poems referenced in this chapter were written in the middle of the shift from mechanism to vitalism and can help trace how poetry allowed different medical theories to be reframed within an imaginative and poetic context to question their implications on the understanding of the human body and what it meant to be alive. These poems mark a period where the concerns of poetry and medicine were intertwined to engage with and question broader cultural anxieties about the body and its workings. These physicians use poetry and poetic techniques to document the mechanical aspects of the body, while also using the poem’s imaginative realm to ask broader questions about what it means to be alive. This chapter will depict some of the complexities and anxieties related to the ‘spark’ of life in the eighteenth century, noting how poets used a mixture of classical materialism and a burgeoning field of vitalism to explore the broader anxieties that were born from differing medical theories of the body. The chapter will show how physician-poetry can be used to map the rise of certain vitalist concepts of life in relation to the medical body from the early to mid-century, moving from religiously charged phrasings of a ‘vital spirit’ in Sir Richard Blackmore’s medico-religious poetry, to a more ambiguous and questioning terminology by later physician-poets trained in Edinburgh. Alongside close reading of the poets’ depictions of life within the body, it will also look at how poetic form lent
Packham, p. .
Packham, p. .
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itself to each poet’s broader aims of depicting contemporary medical theories and the philosophical questioning they prompted.
An Atomic Anatomy Writing the first full-length English anti-Lucretian polemic, Creation, Sir Richard Blackmore turns back to his roots as a physician to inform his poetry and anti-materialist rhetoric: The atheist, if to search for truth inclined, May in himself his full conviction find, And from his body teach his erring mind.
Through the anatomical, the atomic origins of the body can be understood in a divine context. Blackmore argues that if the ‘atheist’ follows their materialist principles to look at their body, they will find a divine truth. Following the animist tradition, Blackmore aligns the body with an immortal soul to prove the importance of the divine in an increasingly secular space of physiological discovery. Publishing Creation in , Blackmore was writing just before the beginnings of the shift from mechanistic to vitalistic ideas of the body. Blackmore’s philosophical poem is presented as a direct challenge to Lucretius’s De Rerum Natura, a classical poem that argues for the atomic origins of the human body and the universe. As Martin Priestman has summarized, the perturbations of Lucretius’s materialist poetics ‘were particularly felt among a large cohort of didactic doctor-poets – [Samuel] Garth, [Richard] Blackmore, [John] Arbuthnot, [Mark] Akenside, [John] Armstrong, [John] Aikin, and [Erasmus] Darwin to name a few – writers not only well-versed in Latin as the internationalist language of their profession, but naturally interested in the psychosomatic ramifications’ of materialism. However, these poetic investigations into the ramifications of materialism were also replete with references to contemporary medicine. Samuel Garth’s The Dispensary is best known for its satirical intervention into the dispensary debates at the Royal College of Physicians in the late seventeenth century. In , the Royal College of Physicians voted on a motion to improve the conditions of the sick-poor in
Richard Blackmore, Creation: A Philosophical Poem in Seven Books (London: Printed for S. Buckley and J. Tonson, ), VI, lines –. Martin Priestman, ‘Didactic and Scientific Poetry’, in Oxford History of Classical Reception in English Literature, Vol. III (–), ed. by David Hopkins and Charles Martindale (Oxford: Oxford University Press, ), pp. – (p. ).
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London by offering non-gratis appointments and setting up a free dispensary for medicine. This motion set the Royal College on a path towards years’ worth of acrimonious dispute and threatened to tear the institution apart. While Garth’s use of poetic form is centred around its function as a mock-heroic medical satire, rhyming couplets also allowed Garth to interrogate the medical and scientific view of the material body at the end of the seventeenth century. Also taking inspiration from Lucretius’s De Rerum Natura, Garth’s vision of the atomistic construction of the body contains multiple references to contemporary medical texts and theories: Now she [Nature] unfolds the faint, dawning strife Of infant Atoms kindling into life: How ductile Matter new Meanders takes, And slender trains of twisting Fibres makes. And how the Viscous seeks a closer Tone, By just degrees to harden into Bone; While the more Loose flow from the vital Urn, And in full Tides of Purple Streams return
Garth references the circulation of blood in a natural metaphor that was often used in medical discourse. In , William Harvey published Exercitatio Anatomica de Motu Cordis, presenting his revolutionary theory of the circulation of blood in the body. The theory is replete with metaphors that influenced a host of poetic interpretations, notably the image of ‘the great River of the whole mass of blood’. In his poem dedicated to physician and philosopher Walter Charleton, John Dryden gives this river a poetic treatment: ‘The Circling streams, once thought but pools, of blood | (Whether Life’s fewel, or the Bodie’s food) | From dark Oblivion Harvey’s name shall save.’ Harvey also appears at the end of Garth’s Dispensary as a shade in the Underworld to lambast medicine’s turn towards profit rather than care: ‘How your sad sick’ning Art now hangs her Head, | And once a Science, is become a Trade.’ In his criticisms of the medical trade, Harvey reminds both Celsus and Hygeia, goddess of health, that ‘I show’d of old, how vital Currents glide, | And the Meanders of their refluent Tide’ to remind the Royal College of Physicians
Samuel Garth, The Dispensary: A Poem. In Six Canto’s (London: Printed for J. and R. in the Strand, ), p. . William Harvey, The Anatomical Exercises ‘De Motu Cordis’ and ‘De Circulatione Sanguinis’ in English Translation, ed. by Geoffrey Keynes (New York: Dover Publications, ), p. . John Dryden, ‘To My Honor’d Friend, Dr. Charleton’, in Walter Charleton, Chorea Gigantum (London: Henry Herringman, ). Garth, p. .
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the true root of their discipline was in the human body (with reference to the ‘meanders’ that opened Garth’s poem) rather than in turning profit. Within this criticism of the medical trade, Garth constructs a version of the ‘Corporeal Substances, and Things unseen’ via poetic rhythms through which one can understand the body as described in Harvey’s theory and contemporary materialist theories of ‘infant Atoms kindling into life’. The opening to The Dispensary follows a similar search for knowledge found in the prefatory poem to another contemporaneous medical text, Samuel Pordage’s English translation of Thomas Willis’s Diatribae duae medico-philosophicae (originally published in ). The poem begins with a search for ‘The intricate and hidden cause of things’, promising that ‘Things hid to former Ages, and unknown, | The Secrets of the world to all are shown’ in the medical text. Willis’s text was responsible for introducing iatromechanism to English medicine by combining chemical explanations of fevers in the blood alongside traditional Galenic therapeutic treatments, such as bloodletting. The prefatory poem summaries Willis’s theory in colourful terms: What Spirit nimbly moves the human frame: Whence Milky juice here, there a Purple stream, Watering the Body: whence the Crimson flood; And the quick Circulation of the blood
These four lines summarize some of the key elements of Willis’s iatromechanical system of the body through poetic means. The ‘Spirit’ that nimbly moves through the human frame references the vital soul that is contained in the blood, where the ‘first beginnings of Life proceed from the Spirit Fermenting in the Heart’. The ‘human frame’ is paired in a part rhyme with the ‘Purple stream’, emphasizing the iatromechanical view of the body as a hydraulic system of pipes through which the blood (and in turn, the vital flame) circulates. The image of the ‘stream’ and ‘flood’ of the blood flowing through the body also marks the natural imagery that was used to describe the circulatory system of the blood through various
Garth, p. . Garth, p. . Samuel Pordage, ‘On the Authors Medical-Philosophical Discourses’, in Thomas Willis, A MedicalPhilosophical Discourse of Fermentation. Or, Of the Intestine Motion of Particles in every Body (London: Printed for T. Dring, C. Harper, J. Leigh, and S. Martin, ), Ar sig. Anna Marie Roos, The Salt of the Earth: Natural Philosophy, Medicine, and Chymistry in England, – (Leiden: Brill, ), p. ; Theodore M. Brown, ‘The Royal College of Physicians and the Acceptance of Iatromechanism in England, –’, Bulletin of the History of Medicine, , (), –. Pordage, Av sig. Willis, p. .
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medical texts and poetry in the following decades. The blood’s circulation through the body was introduced into English medicine through texts such as Harvey’s Exercitatio and Willis’s Diatribae but also reworked and reimagined through poetry. The poetic image of the blood as ‘Purple Streams’, also seen in Garth’s opening lines, was repeated across various medical texts in the following years and gives a sense of how poetic metaphor could be used to interpret medical theory in an imaginative context while also producing a language that could be used in medical texts to further explanations. There is a distinct similarity between Garth’s and Willis’s search for the beginnings of life in the mechanical system of the body and those employed by Blackmore in Creation, where ‘the small pipes are in meanders laid, | And bounding life is to and fro conveyed.’ The reference to the ‘small pipes’ gives a poetic treatment to the iatromechanistic view of the body as a hydraulic machine that is composed of pipes with fluids perpetually circulating through them. Blackmore was evidently influenced by Descartes when producing his philosophical poem, appropriating the Cartesian cogito ergo sum, in his formulation that ‘I think, I move, therefore I am.’ Like Willis, Descartes placed the relationship between the soul and body within the brain and nervous system. Blackmore takes up these physiological developments via a poetic muse who: Sung how the spirits waken’d in the brain, Exert their force, and genial toil maintain; Erect the beating heart, the channels frame, Unfold entangled limbs, and kindle vital flame
Blackmore’s lines depict the concept of the twofold corporeal soul: a vital soul (envisioned as a flame) that was kindled in the blood and a sensitive soul within the brain. These were both distilled in the brain and carried through the nerves into the organs of the body in Willis’s theory, enacted in Blackmore’s verse through the rhymed pairing of the ‘frame’ of the body’s channels and the ‘vital flame’ contained within it. Blackmore consistently questions the divine root of these anatomical processes within the body, asking: ‘When first the womb did the crude Embryo hold, What
See, for example, Daniel Turner, De morbis cutaneis. A Treatise of Diseases Incident to the Skin (London: Printed for R. Bonwicke, J. Walthoe, R. Wilkin, T. Ward and S. Tooke, ), p. and The Art of Surgery (London: Printed for C. Rivington in St Paul’s Churchyard, J. Lacy in Fleetstreet, and J. Clarke under the Royal Exchange, ), p. . Blackmore, p. . Blackmore, p. . Blackmore, p. . Alfred Meyer and Raymond Kierons, ‘On Thomas Willis’s Concepts of Neurophysiology’, Medical History, , (January ), – (p. ).
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shap’d the Parts? . . . What kindled in the Dark the vital Flame[?]’ This ‘vital Flame’ of life is both medical and religious, referencing both the iatromechanistic and Cartesian sense of the soul within the mechanical body and a flame that is inherently divine. When questioning life and matter, Blackmore uses his poem’s rhyming couplets to criticize the materialist arguments for life by appropriating medical and mechanical imagery within a divine framework. Through these poetic explorations into the atomic origins of the vital flame of life, we can mark the poetic recasting of developments in the medical world. Published within two years of each other, Garth’s Dispensary and Blackmore’s Creation both look to the same medical developments to help shape their poetic renditions of the human body and the life that lies within it. However, while Blackmore is concerned with placing his poetry within broader medico-theological debates, Garth is more concerned with using his satirical poetry to comment on the state of the medical profession itself. To return to Carlos Williams’s statement, poetry allows a vivifying of these scientific and philosophical concepts of life, allowing these physicians to turn over contemporary medical theory and practice and question their ramifications through rhymes and rhythms.
Mere Flesh and Blood This exploration of contemporary medical theory in poetry continued throughout the eighteenth century, and the use of poetry was particularly prevalent in the century’s developing vitalism debates. Vitalism was prevalent and central to eighteenth-century Scottish medical education. The medical school at the University of Edinburgh was modelled on the vitalist medical school at Leiden, and through the leadership of the vitalist physiologist Robert Whytt became a leading centre of medical education throughout the eighteenth century. These physicians trained in the Scottish system are products of a Scottish Enlightenment questioning of the nature of man and life, with Packham suggesting that each writer reaches ‘towards alternative means of describing a vital, animating force in the human body whose postulation seems necessary to supplement the inadequacies of a narrow, lifeless mechanism’. John Arbuthnot, a graduate of the medical school at the University of St Andrews, encapsulates much of the vitalist questioning of the nature of man and how to define
Blackmore, pp. –.
Packham, pp. –.
Packham, p. .
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life. Arbuthnot published a poem entitled Gnothi Seaton [Know Yourself] in , a year before his death. The poem opens with a deluge of questions acting as caesurae to slow the reading and enhance a sense of existential panic: What am I? how produced? and for what End? Whence drew I Being? to what Period tend? Am I th’ abandon’d Orphan of blind chance; Dropt by wild Atoms, in disorder’d Dance? Or from an endless Chain of Causes wrought? And of unthinking Substance, born with Thought? ... Am I but what I seem, mere Flesh and Blood; A branching Channel, with a mazy Flood?
The poem was published in the same year as Alexander Pope’s philosophical poem An Essay on Man and considers the same broader concerns as the opening to Epistle II: ‘Know then thyself, presume not God to scan, | The proper study of mankind is Man.’ Arbuthnot uses the philosophical poetic mode to draw links between medical theories and a poetic questioning of the self. These physician-poets can often also be regarded as physician-philosophers, using elements of the developing philosophical poem genre to question what advancing medical and philosophical theories meant for one’s concept of self. Like Blackmore and Garth, Arbuthnot turns to an atomistic description of the body to frame his questions of the self and what it means to be alive. In questioning what it means to ‘know yourself’ Arbuthnot asks what he is, rather than who. To think of himself as ‘mere Flesh and Blood’ and an ‘abandon’d Orphan of blind chance’ leaves him a mere machine and the product of ‘an endless Chain of Causes’, the very reason for his existential panic. Arbuthnot’s existential questioning is in part brought about by the ramifications of the revolutionary medical theories present in Blackmore’s and Garth’s poems. Harvey’s theory of circulation, and the image of blood in the veins as a circling river, is the basis for Arbuthnot’s questioning of himself: ‘Am I but what I seem, mere Flesh and Blood; | A branching Channel, with a mazy Flood?’ He appropriates the various poetic
John Arbuthnot, Gnothi Seaton, Know Your Self: A Poem (London: Printed for J. Tonson in the Strand, ), pp. –. Alexander Pope, An Essay on Man, ed. by Tom Jones (Princeton: Princeton University Press, ), II, lines –.
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depictions of Harvey’s theory, using the ‘purple stream’ image to interrogate the circulation of blood through the body: The purple Stream that through my Vessels glides, Dull and unconscious flows like common Tides: The Pipes thro’ which the circling Juices stray, Are not that thinking I, no more than They
He turns to the tradition of natural imagery to describe these circulatory systems of the body, comparing the flow of blood through the veins with the natural ebb and flow of a river, enhancing these connections through his poetic form with the rhyme of ‘glides’ of blood and the natural ‘tides’ enhancing the body’s unconscious actions. While relying on the same imagery of ‘circling juices’ and ‘common Tides’ as Dryden and Garth, Arbuthnot’s focus is the philosophical ramifications of this imagery. Harvey’s theory had proven that blood circulates round the body’s pipes as a ‘dull and unconscious flow’, but in turn had provoked questions about one’s identity and where the ‘thinking I’ is placed within a body that now appears more mechanistic and unthinking. The answer to making sense of contemporary medical theory was in part found in ancient poetry. The changing atomistic body is ‘mine’ but it is ‘not Me’, Arbuthnot argues, both connecting and dissociating the self with the body. Arbuthnot questions what it means to be alive in this everchanging atomistic body: ‘New Matter still the mouldering Mass sustains, | The Mansion changed, the Tenant still remains’, presenting his interpretation of Lucretius’s sic alid ex alio numquam desistet oriri | vitaque mancipio nulli datur, omnibus usu [so one thing will never cease to arise from another, and no man possesses life in freehold – all as tenants]. Even when the medical body changes, there is an element of self that does not. Arbuthnot questions how we can define this self especially within the context of the medical theories of ‘pipes’ and ‘circling Juices’: What am I then? Sure, of a nobler Birth, Thy Parents Right, I own a Mother, Earth; But claim superior lineage by my SIRE, Who warm’d th’unthinking Clod with heav’nly Fire
Arbuthnot, p. . Arbuthnot, p. . Arbuthnot, p. ; Lucretius, De Rerum Natura, trans. by W. H. Rouse (Cambridge, MA: Harvard University Press, ), III, pp. –. Arbuthnot, p. .
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The human body is one of ‘nobler Birth’ and ‘superior lineage’ for Arbuthnot, and as the product of Earth and God, human life must have been divinely ordained. Arbuthnot turns to the warming force of a ‘heav’nly Fire’ to infuse life into the atomistic body. Within this theory of blood’s ‘dull and unconscious’ circulation around the body, and the body’s cycle of generation and regeneration of atoms, life is something distinctly more than a purely mechanical construction and must be inherently divine. Harvey’s theory of circulation did not do justice to a full description of life itself and the poetic mode, specifically the use of heroic couplets to parallel and contrast, provided a means for Arbuthnot to trace the double nature of man’s body.
The Subtle Principle Within Alone and melancholic while studying in Utrecht, James Boswell turned to his journal to reflect on people who spent their days indulging their melancholia: ‘They do not budge an inch to escape their woes . . . Their blood becomes thick, their brains heavy, their thoughts dark. What a horrible situation! Dr. Armstrong, in his poem on The Art of Preserving Health, gives a description of that state which I have just descried.’ In Boswell, Armstrong found his ideal reader. Through his The Art of Preserving Health, Armstrong set out to portray himself as a sympathetic physician who himself had been a patient and experienced the same pains as his readers and potential patients. In Armstrong’s poem we gain a sense of medicine as a cultural practice, where the poetic lines develop a connection between physician and reader as their rhythms recreate shared symptoms that plague both patient and physician. As Adam Budd notes, the representation of a physician who was vulnerable to the same physical and mental ailments might have been welcomed by readers in a period where physicians were proverbially seen as uncaring and insensitive. The genre and form of Armstrong’s text is heavily influenced by his medical aims. Armstrong’s poetic language, influenced by John Milton, was an attempt to elevate his regimen poem detailing the different paths toward health to a more dignified realm. Armstrong, in a classical innovation of the poetic muses, argues that poetry allows him to fully
James Boswell, Boswell in Holland, –, ed. by Frederick A. Pottle (New York: McGraw-Hill, ), p. . Adam Budd, John Armstrong’s The Art of Preserving Health: Eighteenth-Century Sensibility in Practice (Farnham: Ashgate, ), pp. –. Lawlor, ‘Mere Flesh and Blood’, p. .
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describe the unseen mechanisms of the body in the opening of the poem’s final book. To help uncover the ‘subtle Principle within’ that ‘Inspired with health’, Armstrong calls on the ‘poetic Shades’. These poetic muses ‘know the secrets of the world unseen’ and assist his song as he attempts to ‘wander thro’ [the] mysterious ways’ of how the passions affect the mind and body. Armstrong’s reference to the ‘subtle Principle within’ is likely a reference to the Galenic theory that was central to medical instruction at Edinburgh in the first half of the eighteenth century, detailing material spirits that circulated throughout the body. Poetry is the best means through which Armstrong can begin engaging with the ‘doubtful theme’ of the passions and help explicate this theory of ‘subtle’ or mysterious principles within the body to a wider readership. Armstrong relies on poetic rhythm to depict the mechanisms related to this health-giving ‘subtle Principle’, where the energy of life is one that: . . . by subtle parts, And viewless atoms, secret Nature moves The mighty wheels of this stupendous world. By subtle fluids pour’d thro’ subtle tubes The natural, vital, functions are perform’d.
The repetition of ‘subtle’ across these lines enhance the imperceptible motions of the body that poetry can go some way to describing. Like the small pipes in Blackmore’s and Garth’s poetic exploration of iatromechanistic theories, Armstrong’s ‘subtle tubes’ are the bearers of life throughout the atomistic body. Yet, in contrast, he does not turn to God to explain these vital functions, instead suggesting they are caused by the more ambiguous, but equally non-mechanical, ‘secret Nature’. Armstrong uses these living cycles of the body as a means of defining the inner laws that constitute life. The cyclical functions of the ‘subtle tubes’ are portrayed in the enjambed lines, flowing towards health as the ‘toiling heart distributes life and strength’ and tames ‘the stubborn aliments’. When describing life, Armstrong uses poetic rhythm to mimic the life-giving streams of blood in the body that rely on the same poetic imagery derived from Harvey’s theory of circulation already documented: The blood, the fountain whence the spirits flow, The generous stream that waters every part,
John Armstrong, The Art of Preserving Health: A Poem (London: Printed for A. Millar, ), IV, lines –. Armstrong, IV, lines –. Budd, p. n. Armstrong, IV, lines –. Armstrong, IV, lines –.
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And motion, vigor, and warm life conveys To every particle that moves or lives
The caesura of commas in the lines slows the reading over the ‘motion, vigor, and warm life’, mimicking the ebb and flow of the stream giving life to each part of the body, and allowing the reader a certain metrical space to fully make the parallel between this medical theory and their sense of their own bodies. Returning to the ‘chain of causes’ found in Arbuthnot’s poem, Armstrong turns to the atomistic system of the body, showing that the essence of life is in a constant cycle of growth and destruction. This warm life is conveyed by a ‘vital force’, but not an explicitly divine one. Poetry provided Armstrong a rhythmic system through which to document the constant cycle of growth, destruction, and rebuilding of the organic system that was the basis of life in the human body. Yet near the end of Book II Armstrong infuses a distinct sense of wonder and vitality into this system: ‘Life glows mean time, amid the grinding force | Of viscous fluids and elastic tubes.’ While the general state of man was a system of fluids and tubes, life was something more. Poetry allowed Armstrong to argue that life glows within the bodily cycle of generation and regeneration of atoms that was depicted in prose medical theories.
Conclusion Armstrong concludes his poem by highlighting the intertwined roles of poetry and medicine: Music exalts each Joy, allays each Grief, Expels Diseases, softens every Pain, Subdues the rage of Poison, and the Plague; And hence the wise of ancient days adored One Power of Physic, Melody, and Song.
Throughout his poem, Armstrong uses his poetic rhythms to document the mind and body’s rhythms and cycles as they descend into illness and recover into health. Poetry gave these physicians a means through which they could infuse their medical knowledge of the body with a philosophical questioning. In poetry, they had a space to consider what they knew about the medical body, and in turn question the sense of wonder that lay hidden
Armstrong, II, lines –. Armstrong, IV, lines –.
Armstrong, II, lines –.
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beneath it. It allowed the medical body to be considered alongside religious and philosophical questions about what it meant to be alive. Seen in Blackmore’s copious poetic descriptions of the processes within the human body, and up to Armstrong’s concentration on the atomistic cycles of the body in Book II of his medical instructional poem, these poets turn to their medical training to question the connections between matter and life. As Mary McMurran has noted, vitalism is often ‘seen as a proto-scientific movement due to its association with medical, biological, and chemical experiments’. The reciprocal relationship between poetry and medicine is key to understanding these poems’ unique place within the development of vitalist theory. The figure of the physician-poet, then, can help illuminate the developing vitalist language in the eighteenth century through the combination of poetics, medical theories of the body, and philosophical questioning of the self. In their turning over of the concepts of ‘life’ and ‘matter’, these physician-poets turn to and reinterpret medical theories of the body and infuse them with various interpretations of the ‘vital’ quality of life. The works of these physician-poets show how medical knowledge, materialist poetics, and philosophical questioning combined to produce a poetic exploration of life as the subject of scientific speculation well before the turn of the century, illuminating a prehistory of what many critics have classed as the Romantic uniqueness of vitalist thinking. Medicine in the seventeenth and eighteenth centuries was often rooted in a philosophical questioning, as seen in the previous references to Thomas Willis’s A Medical-Philosophical Discourse of Fermentation. Poetry has been a form that allowed physicians to fully explore these links between medical theories of the body and philosophical questions of the self in a way that medical and philosophical prose could not. While using the term ‘vitalism’ in reference to these eighteenth-century poems might initially seem anachronistic, especially regarding Keats’s and Carlos Williams’s understanding of the term, these poems represent a history of poetry and medicine rejecting a chronological narrative of successive movements. To return to Carlos Williams’s argument that poetry ‘vivifies’ the fields of science and philosophy, these physicians detailed how poetry could allow medical discourse to be reframed to include an imaginative vision of the flame of life, and how on the converse side, the medical world and its knowledge of the body could inform poetic personal expression of the self.
Mary Helen McMurran, ‘Introduction’, in Mind, Body, Motion, Matter: Eighteenth-Century British and French Literary Perspectives, ed. by Mary Helen McMurran and Alison Conway (Toronto: University of Toronto Press, ), pp. – (p. ).
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Healthcare Anecdotes and the Medically Anecdotal Brian Hurwitz
Introduction Just over a hundred years ago, the director of a renowned London teaching hospital overheard a man saying to another patient: ‘“As to them blooming doctors, we teach ’em a lot, I know. Lor’! how they do jaw about our insides to them blokes as sits and looks on.”’ Responding to his gesture towards upturning the epistemological tables of medical practice and displeasure at being made an object of clinical display, the director wrote: ‘The advance of a spirit of surly independence is to be noticed among hospital patients. Time was when as a class they were not ashamed to be grateful.’ The practice of medicine is strewn with anecdotes, brief, pellucid accounts of healthcare episodes cast in dialogues, narratives, and observations, gathered from widely scattered zones of healthcare experience: Some doctors still refer to patients as cases: ‘a case of jaundice’ or ‘a case of diabetes’, as if patients were not people but receptacles of disease. The custom is deeply engrained. Reginald Hilton, a physician at London’s St Thomas’ Hospital in the s, would greet the arrival of ‘a case of syphilis’ with a relish that suggested it had been delivered by his wine merchant.
In positing that patients aren’t people, but collections of vessels brimming with disease, ‘a controlling generality’ is set down over an example of it. More than a diverting reminiscence of the relish a consultant showed in Acknowledgements: Many thanks to Ruth Richardson, John McGowan, Jane Danielewicz, Kim M. Hajek, Tamarin Norwood, John Yudkin, Martina Zimmermann, Neil Vickers, Joe Wood, Max Saunders, John Holmes, John Launer, Graham Matthews, Anna Elsner, and Monika PietrzakFranger for insightful and critical comments on earlier drafts of this chapter. B. Burford Rawlings, A Hospital in the Making. A History of the National Hospital for the Paralysed and the Epileptic (Albany Memorial) – (London: Pitman and Sons Ltd, ), p. . Rawlings, p. . Michael O’Donnell, Medicine’s Strangest Cases (London: Portico, ), p. . John Lyons, Exemplum: The Rhetoric of Example in Early Modern France and Italy (Princeton: Princeton University Press, ), p. .
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dealing with different types of cases, it suggests an underlying resemblance could be at work, which ensures patients are delivered into medical hands as trustily as vintners deliver wine to their customers. Is there something about diagnosing a clinical case that’s akin to bottling and commodifying something? Both sorts of cases are the doctor’s relish, but how does receiving and cellaring wine elucidate the manner in which medicine responds to patients? Is the analogy one of encasement: how someone becomes transformed by diagnosis into a case of a disease, which requires to be understood as no less a human construct than wine is a human product? Or is the anecdote simply a comment on the intersection of profession, class, and privilege in war-torn London, which afforded a doctor opportunities to exercise his talent and tastes as a collector and connoisseur of cases? The stories anecdotes orchestrate stir movements of thought and fantasy, which reorientate and quicken the mind to rework possibilities. Such perspective-shifting accounts, Paul Fleming argues, partake in ‘a narrative form at the nexus of literature and history, in which what is at stake is not chronology, empathy, or identification, but rather and quite simply sense or significance’. By stimulating imaginative explorations and attempts at sense-making, these ‘nutshell-narratives’ help unlock new meanings. Whether in the form of aesthetic compositions or snippets of oral utterance, anecdotes highlight ‘aspects of “patienthood” . . . about which medicine itself is silent’, as in the morsel of talk this chapter opens with, which points to felt vulnerabilities to a way of being looked at, medically. As forms of utterance, contemporary healthcare anecdotes are almost always cast in a vernacular, non-technical language, which differs from that of officially validated medical discourse. I will sketch the development of
Speaking of people as cases is a common, dehumanizing, medical trope. See Lois DeBakey and Selma DeBakey, ‘The Case Report. I. Guidelines for Preparation’, International Journal of Cardiology, , (), –. Paul Fleming, ‘The Perfect Story: Anecdote and Exemplarity in Linnaeus and Blumenberg’, Thesis Eleven, , (), – (p. ). Brian Hurwitz, ‘Anecdotes: Epistemic Switching in Medical Narratives’, in Narrative Science, ed. by Mary Morgan, Kim M. Hajek, and Dominic J. Berry (Cambridge: Cambridge University Press, ), pp. – (pp. , ). John Wiltshire, ‘The Patient Writes Back: Bioethics and the Pathography’, in Renegotiating Ethics in Literature, Philosophy, and Theory, ed. by Jane Adamson, Richard Freadman, and David Parker (Cambridge: Cambridge University Press, ), pp. – (p. ). What sort of looking the man rejected is not precisely detailed, but it’s hard not to wonder whether his complaint foreshadows the ‘medical gaze’ formulated half a century later as a narrowly focused, spatialized perception of the pathological. See Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. by A. M. Sheridan Smith (London: Tavistock Publications, ), p. xi.
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this communicative mode, which emerges from the intersection of history, literature, and clinical cases, and then consider anecdotes recounted by patients or from the perspective of patients and carers, that feature not only vulnerabilities imposed by illness, but inequalities of knowledge and power in healthcare relationships. As verbal and literary accounts, anecdotes constitute a rich repository of episodes whose argumentative and interpretive tropes provide descriptive and moral resources for unlocking insights into the sociality and human relations of healthcare. Understanding anecdotes demands epistemic and ethical openness to the observations and scenarios recounted, and the cognitive space and attention required to make sense of an idiom that attempts to grasp and condense worldly circumstances.
Anekdota The term ‘anecdote’ derives from a compound of three Greek words that denotes ‘a revelation of events previously undivulged’. The earliest extant text entitled Anekdota is Procopius’s exposé of Justinian and Theodora’s mid-sixth-century rule of the Eastern Roman Empire, however, the form is recognizable earlier as a narrative tactic in Aristotle’s works. By the first century BCE, observes Simon Goldhill, anecdotes were an established
A parallel can be drawn with Kenneth Burke’s notion of ‘literature as equipment for living’; Kenneth Burke, ‘Literature as Equipment for Living’, in The Philosophy of Literary Form (Berkeley: University of California Press, ), pp. – (p. ). Peter Burke, ‘The Rise of “Secret History”’, in Changing Perceptions of the Public Sphere, ed. by Christian J. Emden and David Midgley (New York and Oxford: Berghahn Books, ), pp. – (p. ). John McCumber explicates the term as deriving from ekdidomi, comprised of didômi, ‘to give’ and the prefix ‘ek’, ‘out’, meaning ‘to give out’, an adding a negative ‘not given out’. ‘In fact an anekdota (feminine noun) was originally a young woman not yet married, not yet “given out”.’ John McCumber, ‘To Be Is To Be an Anecdote: Hegel and the Therapeutic Absolute’, SubStance, , (), – (p. ). In the Athenian Constitution, Aristotle grants anecdote a role in argumentative advocacy, which as in many later anecdotes, comes to a climax in an oral utterance: Justices . . . often went to the country on circuit in person, inspecting and settling disputes, in order that men might not neglect their agriculture . . .. It was when Peisistratus was making an expedition of this kind that . . . [h]e saw a man . . . digging mere rocks, and because of his surprise ordered his servant to ask what crop the farm grew; and the man said, ‘All the aches and pains that there are, and of these aches and pains Peisistratus has to get the tithe.’ The man did not know who it was when he answered, but Peisistratus was pleased by his free speech and by his industry and made him free from all taxes. Aristotle, Athenian Constitution, Vol. , translated by H. Rackham (Cambridge, MA: Harvard University Press, ), Chapter , unpaginated [accessed August ].
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configuration that ‘organize[d] knowledge in a . . . packaged way . . . [as] short tales or examples [with] an integral role in the construction of the ordinary and the creation of a normative perspective on the world’. For nearly a millennium, the Anekdota was believed to be lost, until the text was discovered in and republished, accompanied by a Latin translation entitled Arcana Historia, or Secret History. It detailed opposition to Justinian’s rule which Procopius had felt unable to publish while the emperor was still alive. Over the ensuing century, other works appeared with ‘Secret History’ in their titles, that offered glimpses of power centred on intrigue, corruption, and deception, and engendered debate about the role of historiettes in the writing of history – brief storied episodes, seen from the ‘back stage of official historiography’. While acknowledging the opportunities such depictions provide for elaborating the interplay between secrecy and revelation, the French historian, Antoine Varillas (–) in his history of the Medicis, rejected wholesale deployment of ‘historiettes inconnues’ and ‘information non publiées’, but applauded ‘Anecdoto-graphers . . . who draw a Picture through Conversation and Witness’, and argued for their selective use, if they illuminated ‘peculiar Connexion[s]’ and ‘notable Events’. Beyond accounts of notable but otherwise hidden events, Isaac D’Israeli in the following century found anecdotes offered minute notices of human nature that reveal the characters of eminent persons in their domestic privacies . . . [rather than in] their public audiences . . . particulars [that] serve the purposes of utility . . . anecdotes of the art as well as the Artist; of the war as well as the General; of the nation as well as the Monarch . . ..
In advising biographers to better acquaint themselves with the lives of their subjects, Doctor Johnson urged authors to consult not only ‘public papers’, but anecdotal sources of information, noting that ‘more
Simon Goldhill, ‘The Anecdote: Exploring the Boundaries between Oral and Literate Performance in the Second Sophistic’, in Ancient Literacies: The Culture of Reading in Greece and Rome, ed. by William Johnson and Holt Parker (Oxford: Oxford University Press, ), pp. – (p. ). Procopii Caesariensis, Anekdota. Arcana Historia. Ex Bibliotheca Vaticana (Lyon: ). Eve Bannet finds that ‘over eighty different works included “Secret History” in their titles, which appeared between and ’. Eve Tavor Bannet, ‘“Secret History”: Or, Talebearing Inside and Outside the Secretorie’, Huntington Library Quarterly, , – (), – (p. ). Malina Stefanovska, ‘Exemplary or Singular? The Anecdote in Historical Narrative’, SubStance, , (), – (pp. –). Antoine Varillas, ‘The Author’s Preface’, in Ανεκδοτα Ἑτερουριακα. Or, the Secret History of the House of Medicis, trans. by Ferrand Spence (London: R. Bentley and S. Magnes, ), unpaginated. Isaac D’Israeli, A Dissertation on Anecdotes (London: Kearsley and Murray, ), pp. vi, , –.
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knowledge may be gained from a short conversation with . . . servants than from a formal and studied narrative’. Joseph Spence (–) made notes of his meetings with Alexander Pope and the conversations he had with the poet’s friends and adversaries, which he considered calling ‘Popiana’, ‘Spenceana’, or ‘Table Talk’, each having a claim on his closely worked accounts of episodes in the poet’s childhood, education, physical and intellectual development, disability, politics, and relationships. For Spence, setting down anecdotes and bringing them to public notice influenced how he shaped them. By the time they appeared in , as Anecdotes, Observations, and Characters . . . of Mr Pope and Other Eminent Persons, anecdotes had become ‘a compulsive mode of representation’, argues David Simpson, through which ‘we understand human nature not by its grand appearances but by the “minute springs and little wheels” that they reveal’, divulgences which extended to medical episodes in a life.
Healthcare Anecdotes Little ‘springs’ and ‘wheels’ are clearly at work in an anecdote that appeared in the Boston Medical and Surgical Journal in , concerning a treatment for colic: Some forty years ago a travelling preacher in England was taken sick with colic, in the house of a good old lady where he was spending the night. The . . . lady brought a bullet, which, after warming, she induced him to swallow. He was soon relieved from pain, and then began to reflect on the
‘Samuel Johnson’, in Biography in Theory, ed. by Wilhelm Hemecker and Edward Saunders (Berlin and Boston: Walter de Gruyter GmbH, ) pp. – (p. ), a reprint of Rambler, ( October ) . Spence provides a source for all his anecdotes, but how much they contribute to each anecdotal formulation and how much they are Spence’s own rendering is unclear. On recounting anecdotes about Pope’s childhood accidents, Spence notes that: ‘the first . . . [was] . . . when he was a child in coats. A wild cow that was driven by the place where he was at play, struck him with her horns ; beat him down, and trampled over him. – Mrs. Racket, his sister was older than him ; and was by when it happened.’ A more elaborate version of the episode – attributed to the same source – reveals that Pope was three years old when attacked by the cow and includes details of the stones he was playing with when attacked, what he was wearing, and the injuries he sustained. Joseph Spence and Samuel W. Singer, Anecdotes, Observations, and Characters, of Books and Men. Collected from the Conversation of Mr. Pope, and Other Eminent Persons of His Time by the Rev. Joseph Spence. Now First Published from the Original Papers, with Notes, and a Life of the Author (London: W. H. Carpenter, ), pp. , . David Simpson, The Academic Postmodern and the Rule of Literature: A Report on Half Knowledge (Chicago: University of Chicago Press, ), p. . Simpson’s quote is from D’Israeli, p. .
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course of the bullet, and thereafter suggested a doubt whether a body so heavy could find its way through the intestinal labyrinth, fearing that it would lodge there permanently. ‘You need not be the least afraid’, said the lady cheeringly, ‘for that very bullet has gone through me at least twenty times’.
This is a tale as much about a relationship in which treatment is offered and accepted outside of a professional medical context as it is about a cure for colic. Once the preacher begins to worry about its possible unwanted effects, his trust in the treatment begins to waver, but impliedly is boosted when the landlady declares that she has, herself, reused it many times. Meant as a reassurance, the revelation reveals what her generosity is built on: retrievals of shot from her faeces and putting it by for future use. Fact or fiction, the anecdote brings to the fore a scene of growing solidarity between two colic sufferers, with innuendos of intimacy beyond those expected of a landlady and tenant. It appeared in the Journal’s Medical Miscellany column immediately after a report of a series of cases of colic: The old remedy for colic, of a bullet of quicksilver taken into the stomach, has been revived, in a modified form, by Dr. Maydieu, of Argent, France. . . . [H]e has been invariably successful in the twelve cases which he has treated with shot. He mixes No. shot, after careful washing, with olive oil sufficient to cover them, and gives a dessertspoonful every half hour. In five or six hours the vomiting ceases, gases are expelled, and the bowels are moved.
By introducing the anecdote to readers ‘[a]propos of this treatment’, the editor suggested he counted it a thirteenth case in this series, as if case and anecdote, each anchored in memory and testimony, could be considered analogues of each other, forms of testimony that bring back elements of a situation or encounter, through picking out what’s particular and noteworthy about it. Accounts of cases and anecdotes recruit capacities to
Anonymous, ‘Swallowing No Shot for Colic’, Boston Medical and Surgical Journal, ( August ), p. . The term bullet refers to a bolus or pellet of materials held together in a binding agent such as grease or honey. Such treatments were by no means unknown in the s: see Anonymous, ‘Case of Lead Colic from Swallowing Small Shot’, London Medical Gazette: Or, Journal of Practical Medicine, (), –. Anonymous, Boston Medical and Surgical Journal, p. . Anecdotes and cases share interconnected framings, which can make it difficult to distinguish them from each other. See Brian Hurwitz, ‘What Archie Cochrane Learnt from a Single Case’, Lancet, (), –; Brian Hurwitz, ‘Narrative Constructs in Modern Clinical Case Reporting’, Studies in History and Philosophy of Science Part A, (), –; Hurwitz, ‘Anecdotes’, pp. –; John Bignall and Richard Horton, ‘Learning from Stories: The Lancet’s Case Reports’, Lancet, (), .
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observe and comment on medical scenarios within a narrative format, but whereas case reports have become the preserve of trained observers, who narrate their findings in a technical, third-person register, in accordance with professional guidelines and reporting standards, contemporary anecdotes continue to be recounted in a vernacular language that does not seek to isolate events from subjective thoughts and feelings about them. For anecdotes, voice and viewpoint are as integral to handling the unusual and strange as catching the fleeting and personal: I know it’s different, isn’t it, after you’ve had the first one. You know the second time what’s going on. So I woke Paul up and we got to the hospital about six o’clock. Of course I walked in, I says ‘OK, here’s my card.’ She goes, ‘You’re not in strong labour yet, you can have a bath.’ I says, ‘I ain’t getting in a bath. I’m going to have it soon.’ ‘No, no, you’ve got plenty of time.’ You know, they won’t listen. I said, ‘No, I know that it’s going to happen fast.’ And of course by the time I go into what they call strong labour at six-fifteen and [sic] she was born at six-thirty. And the doctor wasn’t even there because she hadn’t called him. She’d run a bath and was expecting me to get into the bath.
This spirited remembrance of exchanges between a woman in the critical stages of labour and her midwife, features in an ethnographic study of East London health beliefs, conducted by Jocelyn Cornwell in the early s. It recalls a tumultuous half-hour in the woman’s life, when opposing views rubbed up against each other with an immediacy that heightens the drama she was caught up in. Though things could have gone badly wrong, they probably didn’t, judged by the lack of any reference to physical harm to the woman or her baby. But her experience of labour, and the inferences she drew from it, were apparently not taken seriously; being ignored as an epistemic agent slighted the woman’s self-belief and sense of self-worth, which years later rankled. Fleming finds in anecdotes ‘a narration that claims to present (whether true or not, verifiable or not) a historical event, usually a single event detached from other events’. Although the sensory and cognitive features of the labour are not spelt out in her utterance, at the centre of it is her experiential understanding, grounded in feeling it. Some of what is mentioned could be corroborated from information contained in medical records, but even if unverifiable, the anecdote alerts us to the potential
David S. Riley and others, ‘CARE Guidelines for Case Reports: Explanation and Elaboration Document’, Journal of Clinical Epidemiology, (), –. Jocelyn Cornwell, Hard Earned Lives: Accounts of Health and Illness from East London (London: Tavistock Publications, ), pp. –. See Hurwitz, ‘Anecdotes’, pp. –. Fleming, p. .
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consequences of not taking heed of bodily intuition and feeling, which gestures beyond her own situation, towards the setting in which her labour took place, that could impact on others giving birth and which contributes to the anecdote’s overall meaning and significance. As a casual, untrained observer caught up in labour, the woman’s testimony is open to question; her memory could have become distorted by the passage of time and embellished through multiple retellings, some claims becoming exaggerated, others underplayed. Although the anecdote gives a hearing to an extra-institutional healthcare voice, we learn nothing of the midwife’s understanding of her labour. Cornwell, who interviewed the woman, commented that most of the women [in the study] were totally unprepared for their first experience of childbirth. However, once they had one baby, in their view they were as knowledgeable about the whole process as anyone else . . . seven out of the ten women . . . with more than one child described head on clashes with the staff during the delivery of babies other than their first. . . . These were the only situations . . . in which anyone said that they knew better than medical staff.
Although anecdotes tend to particularize observations, if other accounts of labour in that setting have features in common, the woman’s anecdote may not be as ‘detached’ from its context as Fleming’s formulation suggests. If several anecdotal testimonies independently refer to substantially similar episodes, a narrative inquiry could identify whether components and sequences are shared across accounts, which might suggest her anecdote typifies the way labour is discussed, assessed, and monitored in the setting. Erving Goffman found that anecdotes provide ‘clarifying depictions . . . [which] frame . . . beliefs about the workings of the world, . . . caricatures of evidence [that exhibit] a unity, coherence, pointedness [and] self-completeness’. In compactly setting out dramatic scenarios, they offer potentially penetrating insights into the social and interpersonal relations of
Accounts of events in and beyond healthcare contexts ‘that evoke meaning, interest, and attention for organizational participants’ are referred to in safety discussions as accounts of ‘critical incidents’ in which anecdotes and stories abound. See James G. March, L. S. Sproull, and M. Tamuz, ‘Learning from Samples of One or Fewer’, Quality and Safety in Health Care, (), – (p. ). John Gross, ‘Introduction’, in New Oxford Book of Literary Anecdotes, ed. by John Gross (Oxford: Oxford University Press, ), pp. vii–xiii. Cornwell, p. . Sujane Kandasamy and others, ‘“I Made a Mistake!”: A Narrative Analysis of Experienced Physicians’ Stories of Preventable Error’, Journal of Evaluation in Clinical Practice, (), –. Erving Goffman, Frame Analysis (Boston: Northeastern University Press, ), p. .
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healthcare. Fashioned around discoveries, surprises, and disappointments, these ‘tale[s] that talk’ can be aired and retold in a wide variety of settings, including newspapers, chat shows, lectures, letters, novels, blog fora, healthcare feedback sites, and the submissions pages of patient organizations and public inquiries, each placing differing demands on the shapeliness and register of such accounts. The following anecdote, about a woman’s hospital stay, was one of over five hundred testimonies submitted by patients, family members and friends, to a UK Public Inquiry into the quality of care in a Mid Staffordshire hospital: . . . the patient was admitted to Ward at Stafford Hospital; however, her treatment was ‘rough’ and she was often ‘remonstrated’ by staff, causing her upset. The patient was transferred to a ward that was full of flies. She was informed that a flies’ nest found in a bedside locker had been disturbed and that exterminators had refused to attend over the weekend. When exterminators attended, they simply put sticky paper on the walls and patients continued to be left being covered in flies. The patient had been informed that she should not have blood taken whilst undergoing, or for a period following, her chemotherapy. However, during this time a doctor forcibly took a blood sample causing the patient great distress and delaying her next session of chemotherapy.
The aberrancy of these scenes speaks for itself, but is heightened by the manner in which the original narrator’s voice bursts out of its third-person moorings, as if in a melodrama of episodes that do not follow, one from the other. The purpose of the Inquiry was to consider whether there could be overarching explanations for the episodes of hospital treatment with which it was presented, a point I will return to.
Anecdotes and the Anecdotal Despite the culturally and institutionally sanctioned presence of healthcare anecdotes in a variety of fora, and the role they play in sharing observations, hunches, and ‘hunchy reasoning’, Kathryn Hunter notes that ‘the anecdotal stands very near the top of a list of pejorative words in
Goldhill, p. . Robert Francis, Vol. II Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January –March (London: The Stationery Office, ), p. . See Hurwitz, ‘Anecdotes’, pp. –.
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Healthcare Anecdotes and the Medically Anecdotal
medicine’. Her reference to ‘anecdotal’ is telling, because contemporary medicine is more concerned about anecdote’s adjectival form than about what is an anecdote. Rather than seeing these brief communicative modes as perspicuous accounts of healthcare episodes, medicine focuses on the untrustworthiness of these information packages. The evidence-based clinicians, Murray Enkin and Alex Jadad, define ‘anecdotal information as any type of information informally gained, either from personal or clinical experience, one’s own or that of others, in contradistinction to evidence generated by formal research studies’. They characterize the anecdotal methodologically, by what it is not; it is not information gained from formal, validated, investigative methods, but from a single observation made, for example, in a quasi-standardized manner during a medical consultation, an ethnographic study of beliefs, or plucked from a small number of casual observations for which the error rate is unknown; it is information whose trustworthiness needs to be questioned. Robin Nunn finds contemporary use of anecdotal signifies ‘all that is . . . antithetical to modern scientific medicine. To say, “that’s just anecdotal” is medical jargon for “you don’t know” or “that’s not true’’’; it is to rely on accounts likely to contain biased, untested claims, made by narrators who lack formal training in medical research methods, and show propensities to over-egg their claims. Notwithstanding such misgivings, mainstream medical discourse teems with anecdotal information, bons mots, snappy quips, and repartees exemplifying the successes, virtues, and vices of professional personas, played out in the voices, values, and humour of their medical authors. Yet contemporary medicine’s attitude towards anecdotes and the anecdotal is deeply ambivalent: on the one hand anecdotes are dismissed as accounts no more persuasive than the claims of hearsay, ‘the enemy of objective, dispassionate observation . . . riddled with bias, faulty memory and “foolish optimism”’; on the other, the anecdotal is valued when it takes the form of brief clinical histories. The evidence-based physician, Mark Crislip, argues that: ‘Anecdotes are how patients transmit the
Kathryn M. Hunter, Doctors’ Stories (Princeton: Princeton University Press, ), p. . Murray Enkin and Alex Jadad, ‘Using Anecdotal Information in Evidence-Based Health Care: Heresy or Necessity?’, Annals of Oncology, , (), – (p. ), my emphasis. Robin Nunn, ‘Mere Anecdote: Evidence and Stories in Medicine’, Journal of Evaluation in Clinical Practice, (), – (p. ). See Hurwitz, ‘Anecdotes’, pp. –. Rafael Campo, ‘“Anecdotal Evidence”: Why Narratives Matter to Medical Practice’, PLoS Med, , (), e .
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particulars of their disease to their health care providers. The medical history . . . taken from the patient is an extended anecdote from which the particulars of the disease have to be extracted.’ The task Crislip envisages for the clinician, is how to retell and reformulate (‘extract’ from) patients’ acts of self-witness, biological events and processes that underlie patients’ anecdotally expressed concerns and complaints, from which a case of a medical condition can be constructed. If, as Kathryn Hunter argues, the clinical case is ‘the coin of the medical realm, the medium of clinical thought and communication’, then the anecdote and anecdotal are the informational packages patients tender in medical transactions, snatches of self-observation and -understanding, which constitute the intersubjective materials from which doctors forge clinical experience. The Mid Staffordshire Inquiry received written witness submissions about hospital care, which it renarrated and published in the third person and referred to as ‘evidence’. The Inquiry concluded there was a lack of trained hospital staff, including cleaners, a pervasive fear by employees of all types and seniorities of losing their job, and an institutional culture that lacked insight and capacity to self-criticize. Robert Francis KC, the chairman of the Inquiry, found that ‘the quality of the evidence given . . . the dignity and care with which [it was given] . . . and the sheer number of similar accounts . . . [were] highly persuasive. There is no reason to doubt’, he concluded, ‘that in the vast majority of cases events occurred as they have been described’. In addition to the written submissions, sixty-five people gave oral evidence which was transcribed: [T]he patient attended the hospital after noticing his foot had turned black. . . . [D]iagnosed with a clotting disorder . . . his daughter found her father . . . on the floor . . . his calls . . . ignored by nurses. . . . [She] was shocked that the doctor was excited that he could write an article for ‘The Lancet’ on her father’s condition as he ‘had never seen DIC [Disseminated Intravascular Coagulation] travel so fast on a person’ . . . . [N]urses did not care about her father’s treatment and there was no provision of privacy.
Mark Crislip, ‘A Budget of Anecdotes’, September [accessed September ]. See Hurwitz, ‘Narrative Constructs’. Hunter, p. . The Inquiry took place in the context of raised standardized mortality ratios for several large diagnostic groups of patients admitted to the hospital trust, reviewed in Section G of the report. See Robert Francis, Vol. I Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January –March (London: The Stationery Office, ), pp. –. Vol. I Inquiry, p. .
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Healthcare Anecdotes and the Medically Anecdotal
The patient died four days after being admitted. ‘Only Hitler’s henchmen should die like that; it should not happen to good people in a hospital.’
In rendering a daughter’s account of care not given to her father, the Inquiry couldn’t prevent her voice breaking out of its otherwise passive mode of representation, through which the Inquiry mediated all the testimonies it heard. Apart from her explosive punchline, which it was not possible to remodel, she revealed how the attention one doctor afforded her father was only on account of DIC, the pathophysiology of his dying, and the prospect it offered for publishing a case report in The Lancet. Another submission to the Inquiry described a reality check performed by a woman who struggled with her own disbelief at the hospital scenes to which she became witness: Mrs G, whose late mother (Patient G) . . . had been diagnosed with bone cancer . . . recalls her mother experiencing severe diarrhoea . . . and being unable to find a nurse to clean her . . . . She therefore cleaned her mother herself and was then informed by a nurse that she should not be doing this given her mother’s contagious condition. Mrs G pointed out that Patient G was afforded little dignity and respect, being left to sit in her own faeces in front of other patients’ visitors . . . Mrs G described [the nursing staff] as being extremely busy . . . some were very kind; however . . . others . . . were not . . . patients were not given bedpans in a timely fashion or drinks regularly . . . being left to sit in their own faeces and urine, unable to reach their buzzers . . . her mother’s blood-stained swabs were often left on the cabinet . . . or were dropped onto the floor. On one occasion she decided to leave a blood-stained swab on the floor to see how long it remained there. Three days later it was still there and Mrs G threw it away.
It is clear from the dirt and indignities of life on the ward, that Mrs G’s mother was not the only person in a pitiless state; yet in bringing to notice the ebbs and flows of her attempts to evaluate the situation, she recognizes how busy and kind some of the nursing staff were. The experiment she performed appears to have been motivated by an implicit hypothesis: that a dirty swab would remain on the floor by her mother’s bed for a considerable time – but for how long? As well as a formal test of the ward’s cleanliness regime, her experiment serves as a reality check on whether Mrs G could
Vol. II Inquiry, p. . Vol. II Inquiry, p. . Although the majority of testimonies the Inquiry considered were highly critical of the hospital, many affirmed the care it provided, such as this typical example: ‘Following an operation at Stafford Hospital the patient received “first class” care and attention. The food was good, the wards were clean and the staff were very polite. His wife also attended for painkilling injections and was very grateful for the service she received.’ Vol. II Inquiry, p. . See also pp. , , , , , , , .
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trust her own perceptions. The anecdote reveals that the way people evaluate medical situations depends not only on the trust they place in medical staff, but on how much they – as untrained ‘anecdotal’ observers – are able to trust themselves; can they rely on their own observations, sensations, expectations, and evaluations of healthcare situations? Mrs G’s testimony shows that in this instance her perceptions and interpretations were reliable.
Discussion and Conclusion Anecdotes arise from an irrepressible impulse to make sense of worldly circumstances. Recognized in Graeco-Roman times as ‘a telling story . . . [that] crosses the boundaries between the oral and literate . . . [and] circulates a view of the world with striking efficiency’, for centuries a continuum of sorts operated between a telling medical anecdote and a clinical case. In his Treatises Concerning the Preseruation of Eie-sight (), Walter Bayley (–), the Regius Professor of Medicine at Oxford, recounted the following anecdote: In truth, once I met an old man in Shropshire, called M. Hoorde, above the age of yeares, who had at that time perfect sight, and did read small letters very well without spectacles: he told me, that about the age of fory yeare, finding his sight to decay, he did use [flowers of] Eyebright in ale for his drinke, and he did also eate the powder thereof in an egge three dayes in a weeke, being so taught by his father, who by the like order continued his sight in good integrity to a very long age: I have heard the same confirmed by many old men.
This report, which is a second-order narrative built on multiple encounters and conversations across generations, counts lay observations, beliefs, and inferences as central sources of information in medicine. Narrated in the first person, the report attests to the role of the anecdotal not only in generating information, but in positing causal therapeutic effects. In the eighteenth century, anecdotes revolved around telling facts and insights, deployed in biographies and in the following century, Richard Stoddard (–) argued that anecdotes captured the salient features of a life in ‘trifles . . . which are not trifles . . . incidents . . . a smart saying, a humorous jest, a rapier thrust of wit’.
Goldhill, pp. , . Walter Baley, Two Treatises Concerning the Preseruation of Eie-sight. The First Written by Doctor Baily Sometimes of Oxford: The Other Collected Out of Those Two Famous Phisicions Fernelius and Riolanus (Oxford: Ioseph Barnes, for Iohn Barnes, ), p. . Anecdote Biographies of Thackeray and Dickens, ed. by Richard Henry Stoddard (New York: Scribner, Armstrong, ), p. ix.
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Healthcare Anecdotes and the Medically Anecdotal
The scrims and scrams of information recounted by patients which I have considered, focus not only on the humorous, provocative, and puzzling, but on the inhumane and deadly serious sides of healthcare practices. In setting out medical incidents and turns-of-events, anecdotes, like cases, claim significance beyond the purview of their particulars. Those we have discussed constitute a small and heterogeneous sample of snatches of observations, dialogues, and crafted narratives of witness – aesthetically fashioned second-order depictions – selected for their focus on patient vulnerabilities and concern for loss of dignity and freedom. In making claims, for the most part based on uncontrolled observations that carry epistemic warrant little better than hearsay, medical anecdotes and case reports are often spoken of interchangeably, on account of a shared intersubjective grounding in human interactions and impressions. Although each partakes in aspects and characteristics of the other, by the twentieth century they had become distinct communicative modes. Contemporary patient anecdotes are more emphatic and pointed than case reports; they set up shifts and contrasts in what is the focus of attention; appear in fora outside of mainstream medical publications; are less formally regulated than case reports; and do not shun criticizing healthcare personnel and institutions. Voice and viewpoint are integral to the way they handle their materials, a point reinforced – perhaps unwittingly – by the attempts of inquiries to remodel anecdotal utterances in passive, third-person registers that appear neutrally descriptive, more ‘evidential’. The effect is to pacify voices, de-subjectify views, and take the edge off the experiential and moral tenor of the original accounts. As the testimonies of lay observers who develop inferences not cast in polite, objectivist registers, but in first-person knowing and conviction lingo, anecdotes highlight swerves in the succession of events, and what seems morally or interpersonally wrong or uncertain about them. Rendering such anecdotes in passive registers grants them a veneer of autonomous
See Hurwitz, ‘Anecdotes’. The inquiry into the maternity services provided by the Shrewsbury and Telford Hospital, conducted by Donna Ockendon, reviewed some , reports of serious incidents. The following is typical of the way it rendered patient testimonies: In a family reported that their care after an intrapartum stillbirth was upsetting. Firstly, the family were ‘left in the room for I don’t know how long . . . then put me in a wheelchair, gave baby to me (to hold), put us in a room and left us there’. This family also reported ‘what was worse they put us in the maternity ward so we could hear babies crying’. Donna Ockendon, Conclusions and Essential Actions from the Ockenden Review of Maternity Services at Shrewsbury and Telford Hospital NHS Trust (London: House of Commons, ), p. , see also p. .
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authority in exchange for taming their voices and evaluations (if only incompletely). Despite evident strains and stresses in presenting such materials in this way, inquiries such as those into Mid Staffordshire hospital demonstrate that large amounts of anecdotal information can be triangulated and made sense of, and that the moral awareness embodied in oral and written testimony can be harnessed in attempts to interrogate health services. Goffman’s likening of anecdotes to caricatures alerts us to their capacity to represent situations tendentiously. While literary caricature and its visual counterparts are traditionally associated with somewhat coarse, superficial, and simplistic portrayals that purposely exaggerate features to implicate new meanings, such distortions can be a tactic of viewpoint that picks out elements, traits, or imputed intentions, to adumbrate a grain of truth that would otherwise go unnoticed. Often too partial and incomplete to be counted as straightforwardly mimetic in the absence of verification, anecdotes do not carry a presumptive right to be considered representative or to be believed. As an idiom of episodes – instanced in the account of a nest of flies on a hospital ward, the bullet cure, and how a woman in labour was not listened to – the genre goes beyond episodicity to posit comparisons (the clinical case and case of wine), the testing of hypothetical possibilities (the swab dropped deliberately onto a hospital floor), and possible causal relations (the Eie-sight anecdote) – all of which reflect the grounding of anecdotes in strenuous efforts at sense-making. D’Israeli found anecdotes to bring forth appearances ‘as the glance of lightning discovers what . . . escape[s] us in full light’, momentary visions of a situation, which light up circumstances, as a glimpse opens on an unexpected view that calls forth new thoughts, which help to reshape understanding. Because these arrangements of information refract situations of interest, not only through observations but through viewpoint, caricature, and fantasy, anecdotes provide rich and allusive accounts of healthcare scenarios, that attest to the human determination to apprehend and express the meaning of circumstances, pithily, pungently, amusingly, and tragically.
Olivia Ferguson, Literary Forms of Caricature in the Early-Nineteenth-Century Novel, Doctoral Thesis, University of Edinburgh, . D’Israeli, p. . A similar point is made by V. S. Pritchett, concerning short stories that offer ‘a ‘glimpse through . . . resembling a painting or even a song which we can take in at once . . . [and] bring the recesses and contours of larger experience to the mind’. V. S. Pritchett, ‘Introduction’, in The Oxford Book of Short Stories, ed. by V. S. Pritchett (Oxford: Oxford University Press, ), p. xi.
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Literary Realism and Mental Breakdown Josie Billington
This chapter studies (in translation) two works from different Western cultures and centuries, both of which belong to the category of literary realism. The first is Russian novelist Leo Tolstoy’s Anna Karenina, which helped establish the genre of classic literary realism in the second half of the nineteenth century. The second is Elena Ferrante’s The Days of Abandonment, a twenty-first-century novel which self-consciously continues the realist tradition in the setting of contemporary Italy. The ‘revolution’ of European literary realism in the nineteenth century, wrote Erich Auerbach, was that it gave ‘everyday practical reality . . . a place in literature’. Realism ‘took random individuals from daily life in their dependence upon current historical circumstances and made them the subjects of serious, problematic and even tragic representation’. This staple characteristic of realism – its representation in minute detail of the material and psychological experience of the day-to-day life of individuals in clearly defined social contexts – is what connects the works under discussion here across the ages and socio-cultural milieux which separate them (aristocratic, patriarchal, and quasi-feudal Russia, on the one hand; middle-class, secular, European urban capitalism, on the other). Indeed, realism has proved resistant to more definitive classification in part because it is inherently amorphous, a feature which has been almost as much disparaged (as in Henry James’s famous description of English Victorian novels as ‘loose and baggy monsters’) as it has been celebrated, particularly
Erich Auerbach, Mimesis: The Representation of Reality in Western Literature (; Princeton: Princeton University Press, ), p. . Auerbach, p. . Henry James, Preface to The Tragic Muse (–), in The Critical Muse: Selected Literary Criticism, ed. by Roger Gard (Harmondsworth: Penguin Books Ltd., ), pp. – (p. ).
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in respect of realist fiction’s complex heterogeneity, and rich multiplicity of vision (revealing how ‘the actual world is not a unity and there are many worlds within “the world”’). Even so, it has been customary in literary criticism to contrast the relative formal order and stability of the nineteenth-century realist tradition – especially its confinement to the ‘plausible’ (‘the very stuff of ordinary experience’) in terms of character trajectory and plot teleology – with the Modernist formal experimentation which (partly reactively) succeeded realism in the early twentieth century. Literary realism, critical orthodoxy asserts, is inimical to dissolution. Realist fiction resists and opposes the breakdown and chaos in experience which modernist novels, by contrast, formally embrace. This is the consensus not only among postmodern theorists of nineteenth-century realism – for whom the realist tradition is an ideological endorsement, above all, of dominant socio-cultural power structures and norms – but also among critics wholly sympathetic to the genre. Realism is a quintessentially ‘middle mode’ which eschews extremes. The conventions of realism’s ‘middle distance’ engender ‘formal agreement about the conditions of perception’ which ‘assure us that we all inhabit the same world and that the same meanings are available to everyone’. In realist narrative, ‘a stable invariant world is there . . . because everyone agrees that is so’. ‘The realist cannot present,’ says Robert Anchor, in deliberate critical counter to deconstructionist exposés of realism’s ideology, ‘as we cannot live in, a wholly meaningless world. The attempt to make a fiction from, and match it against such a world, leads beyond the limits of Realism.’ Nonetheless, it remains the case, paradoxically, that writers in the realist tradition, from
Most influentially in Mikhail Bakhtin’s The Dialogic Imagination, trans. by Caryl Emerson and Michael Holquist (Austin: University of Texas Press, ): see especially Essay Four, ‘Discourse in the Novel’, pp. –. Raymond Tallis, In Defence of Realism (London: Edward Arnold, ), p. . M. H. Abrams and Geoffrey Galt Harpham, A Glossary of Literary Terms, th edn (Boston: Wadsworth Cengage Learning, ), p. . Abrams and Galt Harpham, p. . Catherine Belsey, Critical Practice, nd edn (London: Routledge, ); Colin MacCabe, ‘The End of a Meta-Language: From George Eliot to Dubliners’, in George Eliot, ed. by K. M. Newton (London: Longman, ), pp. –; Jean-François Lyotard, ‘Answering the Question: What Is Postmodernism?’, trans. by Régis Drurand, in The Postmodern Condition, trans. by Geoff Bennington and Brian Massumi (Manchester: Manchester University Press, ), pp. –. J. P. Stern, On Realism (London: Routledge and Kegan Paul, ), p. . Elizabeth Deeds Ermarth, Realism and Consensus in the English Novel: Time, Space and Narrative (Princeton: Princeton University Press, ), pp. xix, , , . Ermarth, p. . Robert Anchor, ‘Realism and Ideology: The Question of Order Author(s)’, History and Theory, , (), – (p. ).
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Literary Realism and Mental Breakdown
its nineteenth-century heyday to the present, have found realist narrative not only accommodating of psychic disintegration but, as we shall see, even necessary to its adequate depiction. In this chapter, I explore not only the overlooked presence of mental breakdown in realist fiction, but realism’s special value as a document of psychic chaos envisioned as an aspect of ordinary existence irreducible to a symptom of abnormality merely. As already stated, I will be concerned with two novels in the realist tradition. Leo Tolstoy’s Anna Karenina () belongs historically to a period which saw at once the established generic dominance of the realist novel in Western literature and the foundation of psychoanalysis. The proposition that these coincident phenomena are cultural responses to ‘a world abandoned by God’ is no negligible consideration for this chapter. Elena Ferrante’s early twenty-first-century novel, The Days of Abandonment (), is steeped, as we shall see, in the traditions of both realism and psychoanalysis, in relation to metaphysical questions and predicaments that prove no less pressing for Ferrante’s protagonist than for Tolstoy’s. The equivalence of these heroines’ struggles across their distinct sociocultural contexts and a century and a half of Western cultural experience, poses the possibility (which I partially confront towards the close of this chapter) that problems characterized as originating in mental disease in the current century, might owe their origin to the absence of guaranteed meaning occasioned by the general cultural loss of the certainties of religious belief, and the precarious adequacies of the totalizing frameworks which have sought to replace them. Nor is it mere coincidence that both novels are concerned with female protagonists who (of their day) are modern cultured European women in failed marriages. Indeed, the protagonist of the later novel explicitly invokes the example of her forebear in the earlier work. Tolstoy’s Anna Karenina is a constant touchstone of brokenness for Ferrante’s protagonist Olga, who is herself breaking down. Analogously, classic literary realism is avowedly a prior model for the writer, whose uncompromising ‘passion for realism’, to ‘tell the thing as it is’, is a non-negotiable starting point of her every creative endeavour. One contention of this chapter is that realism’s models – so compelling for later writers who demonstrably have modernism and psychoanalysis as part of their repertoire – have been unfairly overlooked in the custom of
Georg Lukács, The Theory of the Novel, trans. by Anna Bostock (London: Merlin Press, ), p. . Elena Ferrante, In the Margins: On the Pleasures of Reading and Writing (London: Europa Editions, ), pp. –.
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turning to literature for templates of psychic phenomena. Modern psychoanalysis and the therapeutic professions can potentially learn, I argue, from the many-levelled realities of which realism is constituted. The mental breakdown of initial concern in this chapter is the kind which occurs, paradoxically, in evasion of disintegration. In his crucial chapter on psychic pain, J. B. Pontalis, drawing on Freud’s definition of the same across his oeuvre, asserts that pain’s ‘first essential characteristic’ is ‘the phenomenon of a breaking down of barriers’ occurring when ‘excessively large quantities of [mental] energy break through the protective devices’. ‘Pain is an effraction, it presupposes the existence of limits: limits of the body, limits of the ego, it brings about an internal discharge, which could be called an implosion effect.’ Freud’s own term (‘unusual for Freud’ says Pontalis) was ‘internal haemorrhage’. The phenomenon of psychic pain thus defined is, in Wilfred Bion’s terms, the exploding of the container (body, ego, identity) not by the contained, but by content that cannot be contained. The haemorrhage cannot be staunched, but is unstoppable; the transgression of limits is itself without limit: ‘An excess of excitation hinders any binding activity . . . the too full creates a void.’ ‘Pain [is] at the frontiers and juncture of body and psyche, of death and life.’ Faced with primary pain that cannot be withstood, and that can be experienced or truly suffered only at the cost of annihilation, the psyche fashions its own container, building a mental structure ‘to avoid at all costs the encounter with the original pain’. The psyche organizes its territory so as to operate within fixed parameters, neutralizing affect, reducing functioning to a ‘closed circuit’. Pontalis gives the example of -year-old Simon, orphaned as a small boy during the Holocaust, whose early dissociation determined his entire mental functioning: ‘What survived . . . was an extraordinary machine . . . to register daily life (on condition that it remained petrified). He had built himself a closed system of enclosures and separations – a sort of mental concentration camp.’ This is an example of why psychoanalysis must be
For an extended discussion see: Josie Billington and Philip Davis, ‘Realism’s Concealed Realities’, Synthesis: An Anglophone Journal of Comparative Literary Studies, (), –; Josie Billington, Is Literature Healthy? (Oxford: Oxford University Press, ), ch. . J. B. Pontalis, Frontiers in Psychoanalysis: Between the Dream and Psychic Pain, trans. by Catherine Cullen and Philip Cullen (London: The Hogarth Press, ), p. . My thanks to Jivitesh Vashisht for his insights on the relevance of this work to my project. Pontalis, p. . Pontalis, p. . Wilfred Bion, Elements of Psychoanalysis (; London: Karnac Books, ), p. . Pontalis, p. . Pontalis, p. . Pontalis, p. . Pontalis, p. . Pontalis, pp. –.
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Literary Realism and Mental Breakdown
painful, says Bion, ‘not because there is necessarily any value in pain’, but because ‘there is a need for the analytic experience to increase the patient’s capacity for suffering even though patient and analyst may hope to decrease pain itself’. If an impairment of ability to experience pain is not dealt with, ‘the patient’s capacity to maintain the static situation’, rather than dynamically confront and suffer the original pain, ‘may give way to an experience of pain so intense that a psychotic breakdown is the result’. The ‘static situation’ might itself be a painful one, in which a person aggressively endures one kind of suffering, as a means of ‘holding at arm’s length something that is more intolerable’. Pontalis cites the noisy repetitive behaviours of René, who forces others to undergo what he has undergone as the son of an obsessive and possessive mother and alcoholic and absent father: ‘He must be ceaselessly active [with] no slight void within himself which permits the play of presentation, the eruption and perspective of memories: it is always the same scenes that are evoked, in which he occupies, of course, the position of the powerless, enraged victim.’ What is at stake here is not the avoidance of unpleasure. This is suffering. But it is a secondary suffering which ‘serves as a screen for’, or ‘to evacuate’, psychic pain, such that the latter is only ‘tangible a contrario’. Where Pontalis and Bion give examples from their own psychoanalytic practice, I offer a fictional example, from Anna Karenina, of this phenomenon whereby the avoidance of primary pain reactively and secondarily produces catastrophic suffering in relation to another substitutive pain. In doing so, I employ and extend the time-honoured practice of using literary examples as a specialized form of empirical data both to demonstrate the tenets of psychoanalysis and to enrich the repertoire of its models. As already stated, the realist novel has been largely disregarded in this respect, a neglect which is the more remarkable given that realism is the literary medium par excellence for the close analytical observation of individual lived experience.
Anna Karenina: Literary Realism as Case Study – The ‘Closed Circuit’ of Psychic Pain The passage below occurs at the close of Book Six. Anna, having left her husband, Karenin, and her son, Seryozha, is living with her lover, Vronsky, and their daughter, in seclusion in the countryside. Ostracized by Russian
Bion, pp. –. Pontalis, p. .
Bion, p. . Pontalis, p. .
Pontalis, p. .
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Pontalis, p. .
aristocratic society and feeling increasingly isolated, Anna has become obsessively afraid of losing Vronsky – to society, a profession, or, in particular, another woman. She has been repeatedly urged – by Vronsky, by her brother, Oblonsky, and by her sister-in-law, Dolly – to seek a divorce from Karenin in order to regularize her position. Anna’s response is consistently evasive: ‘Anyhow of that later’; ‘We’ll talk about all that later’; ‘It’s too terrible. I try not to look.’ ‘She doesn’t see and doesn’t want to see’, declares Vronsky, and Anna’s not seeing is increasingly literal: Dolly frequently notices Anna’s ‘strange new habit’ of ‘narrowing her eyes as if peering at something in the distance’ when ‘it was a matter of the most intimate sides of life’. Despite Anna’s efforts to fill her time with activity, ‘her chief concern was still . . . herself, in so far as she was dear to Vronsky’. Meantime, Vronsky, in a knock-on consequence of Anna’s behaviours, feels the pull of the social freedoms which, relative to Anna’s compromised situation as a female adulteress, he enjoys. The following passage occurs after one of the couple’s partings: Before () Vronsky left for the elections, Anna, considering that the scenes repeated each time he left might only make him colder and not bind him to her, decided to try as hard as she could to calmly endure her separation from him. But the cold, stern look he gave her when he came to announce that he was leaving offended her, and even before () he left her calm was already broken. Later, when she was alone, she thought about that look, which expressed his right to freedom, and arrived, as always, at one thing – the awareness of her humiliation. ‘He has the right to go off wherever and whenever he wants. Not only to go off but to abandon me. He has all the rights and I have none at all. But, knowing that, he shouldn’t have done it. And yet what did he do? . . . He looked at me with a cold and stern expression. Of course, that is indefinable, intangible, but it wasn’t so before, () and that look means a lot’, she thought. ‘That look shows that the cooling off has begun.’ And though she was convinced that the cooling off had begun, still there was nothing she could do, she could not do anything in her
Leo Tolstoy, Anna Karenina, trans. by Richard Pevear and Larissa Volokhonsky (; London: Penguin Books Ltd., ), p. . Tolstoy, p. . Tolstoy, p. . Tolstoy, p. . Tolstoy, pp. , . Tolstoy, p. . Tolstoy, p. . Tolstoy, p. . For ease of reference, I embolden features of the text discussed in what follows.
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Literary Realism and Mental Breakdown
relations with him. Just as before (), she could only try to keep him by her love and attractiveness. And, as before (), by being occupied during the day and taking morphine at night, she could stifle the terrible thoughts of what would happen if he stopped loving her. True, there was one other means, not to keep him – for that she wanted nothing but his love – but to get so close to him that he could not abandon her. That means was divorce and marriage. And she began to wish for it, and decided to agree to it the very first time he or Stiva brought it up. A clue to the closed circuit which characterizes Anna’s defensive mental structure is the fate of the adverb ‘before’ in this passage (numbered in the text to highlight its transformation) which on no occasion stably or singly signifies time past. () denotes the run-up to Vronsky’s departure in which Anna has schooled her reactions in anticipation of that event, by looking back at earlier ‘befores’ – ‘the scenes repeated each time he left’. () indicates the period of Vronsky’s imminent (pre-)departure in which her loss of calm, nonetheless, is identical with her agitation, post-departure. () refers to the period prior to the couple’s growing estrangement which, in emphasizing the latter by contrast, generates the future: ‘the cooling off has begun’. () and () are equivalent to ‘as always’ in paragraph , signalling helpless repetition. Indeed, there is nothing to distinguish the ‘Before’ which opens paragraph from the ‘Later’ which opens paragraph since both ‘arrive’ at the same ‘one thing’. It is because time itself has become not a determinant of story but, distortingly, a function of Anna’s disordered mentality, that Anna’s effort to use temporal events to get out of her mind, as it were, in order to escape her pain, only recreates further reactive distortions rather than providing release. ‘She decided to agree to [divorce and marriage] the very first time he or Stiva brought it up.’ Given that the subject of virtually every conversation in Book Six has been the indefiniteness of Anna’s position (which not only renders her socially and legally ‘outcast from the society in which she is naturally at home’, but which, without a divorce, makes her daughter, and any future children by Vronsky, the property of her husband, Karenin), the ‘very first time’ is already inevitably doomed to be a repetition of past evasions of this question. ‘She began to wish for it’ is as
Tolstoy, pp. –. John Bayley, Tolstoy and the Novel (London: Chatto & Windus, Ltd. ), p. .
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arbitrary, and as mentally orchestrated, a new beginning as ‘the cooling off has begun’. In further demonstration of that closedness, a whole book later nothing has changed. The couple have argued over Anna’s attention towards an English protégée (‘I am not interested in your concern for this girl, because I can see it’s unnatural’, says Vronsky): Today he had not been home all day, and she felt so lonely and so pained to have quarrelled with him that she wanted to forget it all, to forgive and make peace with him, wanted to accuse herself and justify him. ‘It’s my own fault, I’m irritable, I’m senselessly jealous. I’ll make peace with him, we’ll leave for the country, I’ll be calmer there’, she said to herself. ‘Unnatural!’ – she suddenly remembered the most offensive thing, not the word so much as the intention to cause her pain. ‘I know what he wanted to say. He wanted to say that it’s unnatural for me to love someone else’s child when I don’t love my own daughter. What does he understand about the love for children, about my love for Seryozha, whom I have sacrificed for him? But this wish to cause me pain! No, he loves another woman; it can’t be anything else.’ And seeing that, while wishing to calm herself, she had gone round the circle she had already completed so many times and come back to her former irritation she was horrified at herself. ‘Is it really impossible? Can I really not take it on myself?’ she said to herself, and began again from the beginning. ‘He’s truthful, he’s honest, he loves me. I love him, the divorce will come any day now. What more do we need? We need peace, trust and I will take it upon myself. Yes, now, when he comes, I’ll tell him it was my fault, though it wasn’t, and we’ll leave.’
The to-fro dynamic of accusation > justification > accusation, familiar from the passage quoted above (‘Knowing this, he ought not to do it! But really what has he done? . . . It wasn’t so before . . . the cooling off has begun’), is repeated here: ‘She wanted to accuse herself and justify him . . . she suddenly remembered the most offensive thing . . . ‘I’ll tell him it was my fault, though it wasn’t.’ In both cases, the momentum from one impulse to another occurs not in relation to Vronsky but in relation to Anna’s inner memory of a look (‘stern, cold’) and a word (‘Unnatural!’). As with time in the previously quoted passage (‘Before . . . Later’), here emotions (blame and forgiveness, love and hate) are moving in their own sequence, increasingly separated from their object (Vronsky) and from the
Tolstoy, p. .
Tolstoy, pp. –.
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Literary Realism and Mental Breakdown
reality of their holder’s situation. The circle damagingly recreates itself (‘she began again from the beginning’ is a reflex of ‘she was horrified at herself’) because, without the definition that the repetition of this sequence gives her, almost insufferable though it is, what Anna would remain? She goes on and on holding herself together in an inauthentic way even though it is that which is destroying her. False self-integration puts her beyond risk of disintegration at one level, and beyond rescue from the same at another. Anna is a brilliant example of what Pontalis calls ‘the organized refusal to encounter [pain]’. Pain is suffered ‘a lot, at the necessary time and for the necessary duration in order not to [be] suffer[ed] too much and for ever’. The ‘fixed dialectics’ produce a damaging suffering which is nonetheless ‘secondary to a naked absolute pain’. The pre-existence of the literature in relation to the theory, from a writer ‘innocent’ of psychoanalytic theory and its determining agenda, offers a kind of primary, authentic evidence of psychoanalytic events. But literature is generally invoked for these purposes at the macro level of dramatic narrative event (most famously in Freud’s appropriation of Oedipus Rex in The Interpretation of Dreams). What realism makes visible in these instances is psychic phenomena at a micro level, disclosing the specific circular grammar of the avoidant closed circuit of psychic pain, to which only the analyst ordinarily has access. But psychological realist fiction takes psychic pain out of the consulting room, as it were, in another important sense too. For we are given the micro story together with the macro story. We witness these terrible inner vicious circles more than pages into a novel which has registered the pressure of the domestic, personal, sociocultural, and legal forces that bear upon Anna, from the emotionally impoverished domestic environment of her unhappy marriage to the gender bias of the divorce laws. The latter, by rendering her son the property of her husband, engender their own cruel circle: she cannot divorce and, in not divorcing, she can have no definiteness. The psychic life registered in these passages is not a ‘laboratory’ phenomenon, shorn from the surrounding context of a life in time as psychoanalytic case studies can so often appear to be. Anna’s psychic micro-story is never separate or separable from the macro-story which is
Pontalis, p. . Pontalis, p. . Pontalis, p. . For critiques of psychoanalytic theory that highlight the tendency to neglect social context and prioritize inner life over external realities, see: Laura S. Brown, Feminist Therapy (Washington, DC: American Psychological Association, ); Paul L. Wachtel, ‘Knowing Oneself from the Inside Out, Knowing Oneself from the Outside In: The “Inner” and “Outer” Worlds and Their Link through Action’, Psychoanalytic Psychology, , (), –.
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itself experienced by the reader with microscopic intimacy. This capacity to incorporate multiple and overlapping (inner and outer) realities without ever departing from the stringent test of the ordinary real is a crucial aspect of realism’s disciplined openness to which I return at the close of the chapter. But first I wish to contend that realism’s depiction of mental pain, thereby, has a depth, width, and richness unavailable to the interpretive authority of the psychoanalytic case study, on the one hand, or the subjective accounting of autobiographical trauma narrative, on the other.
The Days of Abandonment: Literary Realism and Fragmentation Let me test this claim in relation to Ferrante’s novel, which, as a contemporary first-person narrative steeped in psychoanalytic understanding, is self-consciously situated somewhere between these two modes. In Frantumaglia, Ferrante writes of her ‘love’ of Freud’s work and her ‘passionate’ reading of Melanie Klein, and her world view is imbued with these thinkers’ ideas. Psychoanalysis, Ferrante writes, is a ‘powerful stimulus for those who want to dig inside’; it possesses a ‘visionary boldness’ which cannot be ignored, and which ‘conditions us even when we reject it’. But reject it Ferrante does in her novels, finding psychoanalytic theory of only ‘ambivalent usefulness’. Its named and ordered psychic reality, capable of ‘saying everything and nothing’, is ‘ice’ to the ‘inventive force’ which discovers the irreducible, individual psychic disorder where there are ‘no reassuring signposts’ or ‘soothing formulas’. Interestingly, Ferrante attributes to the psychoanalytic narrative here the very same ‘task’ which (so Lyotard argues) has been ‘assigned to realism’ in the service of capitalist hegemony: the stabilizing of reality, ‘arrang[ed] according to a point of view which endows it with a recognisable meaning’, to ‘preserve various consciousnesses from doubt’. Ferrante, however, chooses that same ‘ordering’ principle of realism as a first essential step in destabilizing her material, as demonstrated by the author’s own account of her artistic process: ‘I begin with an integrated type of writing, based on consistency, which establishes a world with all its scaffolding in the right place. It’s a solid cage: I construct it using the necessary facts of reality.’
Elena Ferrante, Frantumaglia (London: Europa Editions, ), p. . Ferrante, Frantumaglia, p. . Ferrante, Frantumaglia, pp. –. Ferrante, Frantumaglia, p. . Ferrante, Frantumaglia, pp. , . Lyotard, p. . Lyotard, p. . Ferrante, In the Margins, p. .
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Literary Realism and Mental Breakdown
In The Days of Abandonment, Olga’s psychic disturbance is duly saturated with ‘necessary’ circumstance. When Olga’s husband, Mario, leaves her for a younger woman (the event which catalyses her breakdown), she feels heavily ‘the weight of the two children – the responsibility but also the physical requirements of their lives’. ‘The children, the dog, shopping, lunch and dinner, money. Everything pointed out to me the practical consequences of abandonment.’ The practical and diurnal – the sheerly ‘physical’ – burden of life as a suddenly single mother is no mere contingency but the ineluctable reality in which Olga’s disintegration takes place. The literal medium in which the character moves and acts is continuous with the literary one in which the author operates. Literary realism’s ‘unabating interest’, says Stern, is in the ‘ballast, rubble, detritus [which weigh down this world]’ . . . ‘the shapes and relations of the real world’. For Ferrante, it is the robustness of the ‘cage’ of realism which makes possible the ‘convulsive, disintegrating type of writing’ that ‘drill[s] into the internal lands’, the ‘incandescent lava’, ‘the pure specific inner disorder’ of the individual, ‘searching beyond the tested vocabulary’, ‘beyond any system, beyond any analysis’. This is what the author ‘patiently’ waits for, she says, while obeying the strictures of chronological narrative. In Ferrante’s work, realism’s necessary facts of existence, even in their relatively amorphous disorder (‘rubble, detritus’), are to explosive psychic suffering what Apollonian order and discipline are to Dionysian energies in Nietzsche’s The Birth of Tragedy. They need one another and this mutual dependence operates at every level of the work. Thus, Olga’s inner ‘lava’ erupts inside a mundanity which (albeit barely) holds it together. Olga describes herself as being ‘like a boxer who no longer remembers how to move and wanders around the ring with his legs buckling and his guard lowered’. She becomes unstable to the point of forgetting the existence of her children, fantasizing about the sexual life of her husband and his lover, involuntarily uttering obscenities, and at one point, in a darkly comic and public act of violence, attacking her husband in the high street. Her blood deafens her, her breath chokes her, her voice is ‘more a sound in my head than a reality’, and she has a suddenly fearful sense that she will ‘dissolve into liquid’. ‘I couldn’t contain myself.’ ‘I tried to tell’, says Ferrante, ‘what a destabilising force is
Elena Ferrante, The Days of Abandonment (London: Europa Editions, ), p. . Ferrante, Abandonment, p. . Stern, pp. , . Ferrante, In the Margins, p. . Ferrante, Frantumaglia, pp. –. Ferrante, In the Margins, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. .
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released even today, even when the abandoned woman has considerable tools for defence, resistance, counterattack. Often the narration of the crisis appeared to rest on quicksand.’ Realism’s formal ‘scaffolding’ is thus malleable and porous to primary disorder, and able to contain it, in a way, Ferrante suggests, that the programmatic orthodoxy – the ‘cool finds’ and ‘soothing formulas’ – of psychoanalytic theory cannot. At the same time, while the novel is using realism’s ability to tolerate being taken, with the protagonist, to the edge of its own formal annihilation, what in part saves Olga, almost dizzyingly, is the ‘reality principle’ itself: ‘I was desperately vigilant about the obligatory daily tasks, be careful to salt the pasta, . . . to note the expiration date of food, . . . not to leave the gas on.’ ‘Do the laundry. Separate the dark clothes from the white. Start the washing machine.’ ‘Occupied on two fronts’ – ‘the reality of the facts’ and the inner reality of dissolution, she goads herself: ‘Remember to do this, remember to do that. . . . Pay attention I said to myself’; ‘Don’t succumb . . . Fight’; ‘I was holding tight around me the parts of my life . . . in spite of everything I wasn’t leaving myself.’ One way realism’s fine-grained ‘patient’ observation of psychic phenomena helps to dismantle entrenched psychoanalytic categories is by showing that Olga’s use of the banality of the mundane real, as a defence against dissolution, is a mere hair’s-breadth away from Anna’s escape into activity and doing. How little seems to separate the survivor from the destroyed. This is the opposite of a ‘fixed dialectic’: it is a wholly mobile one built into the form of realism itself. Such is Olga’s own experience when her chief ‘goad’ becomes not reality, but literary realism, and specifically the example of Anna: ‘[Olga] is combative, she doesn’t want to be Anna Karenina. . . . Struck as she is by the unendurable experiences of disintegration . . . overwhelmed by it, . . . yet she resists . . . and saves herself and her children from death.’ But resistance is an outcome, after months of denial, of Olga’s, suddenly and unequivocally, seeing herself in Anna: ‘in bad shape, definitively broken’. Making a habit of writing in her notebook, Olga finds, almost at the dead centre of the book, that she has unwittingly written down, and
Ferrante, Frantumaglia, p. . Ferrante, Frantumaglia, p. –. Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Ferrante, Frantumaglia, pp. –, . Ferrante, Abandonment, p. .
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underscored in red, the questions Anna asks herself directly before her suicide – ‘Where am I? What am I doing? Why?’: Nothing was solid, everything was slipping away. I stared at my notebook, the red lines under Anna’s questions like a mooring. . . . I didn’t know how to find answers to the question marks, every possible answer seemed absurd. I was lost in the where am I, in the what am I doing. I was mute beside the why.
The ‘mooring’, significantly, is not the words themselves, but the red lines which signal Olga’s involuntary recognition that she ‘seemed to know [the questions] well’. The questions are the opposite of an anchor, in fact. She cannot lean on them. She is ‘lost in’ them. They are ‘an unstable landscape, an infinite aerial or aquatic mess of debris that appears to the I, brutally, as its true and unique inner self’. Olga has, in fact, become Anna psychically, even suffering the same physical symptoms of psychic disorder (‘You’re doing terrible things’, her young daughter tells her, ‘your eyes are all twisted’). There is something truly remarkable about Olga’s ‘definitive’ confrontation with this primary pain, and near dissolution, occurring not in the modern psychoanalytic encounter, but in relation to a psychic reality existing within the relative safety and stability of nineteenth-century realist fiction. Literature, says Ferrante, ‘orchestrate[s] lies that always, strictly, tell the truth’. I return to this paradox at the close of the chapter. But what is the primary pain behind – or in – those ‘Where, What, Why’ questions? What primal scene is Olga facing, as surely as Anna is evading it, even at the cost, at the last, of her physical destruction? And how does literary realism’s accounting of this pain enrich our understanding of it? On the one occasion where Anna seems to look her situation squarely in the eye, her pain relates apparently to her son, Seryozha, from whom she is estranged. She says (to her sister-in-law, Dolly): ‘You must understand that I love two beings – equally, I think, but both more than myself – Seryozha and Alexis. . . . I love only these two beings, and the one excludes the other. I can’t unite them, yet I need only that. . . . It will end somehow, and so I can’t – I don’t like talking about it.’
The one and ‘only’ need relates irresolvably to ‘two beings’. The central incompatibility – that Anna cannot ‘marry’ Vronsky and Seryozha instead
Tolstoy, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Ferrante, Frantumaglia, p. . Ferrante, Abandonment, p. . Ferrante, Frantumaglia, p. . Tolstoy, p. .
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of Vronsky and herself – appears to be the key not only to Anna’s refusal to seek a divorce, but to her incoherence. Compare immediately, however, this passage from much earlier in the book, when Anna has first made full confession to Karenin of her feelings for Vronsky: She kept repeating: ‘My God! My God!’ But neither the ‘my’ nor the ‘God’ had any meaning for her. Though she had never doubted the religion in which she had been brought up, the thought of seeking the help of religion in her situation was as foreign to her as seeking help from Alexei Alexandrovich. Not only was it painful for her, but she was beginning to feel fear before the new, never experienced state of her soul. She felt that everything was beginning to go double in her soul, as an object sometimes goes double in tired eyes. Sometimes she did not know what she feared, what she desired: whether she feared or desired what had been or what would be, and precisely what she desired, she did not know.
The grammar of the later passages is all here already pages earlier. There is the mental circle – ‘she did not know . . . she did not know’ – in which fear and desire are now the mutually re-creative emotions. There is the doubling of one into two, at psychic and physical levels, soul and sight (‘eyes’). But her son, Seryozha, is not now at the equivocal centre of this circle but (like the idea of divorce or of leaving in the previous passages), the extempore means of vacating it: Seryozha? What about Seryozha? . . . The reminder of her son suddenly brought Anna out of that state of hopelessness which she had been in. She remembered the partly sincere, though much exaggerated, role of the mother who lives for her son, which she had taken upon herself in recent years, and felt with joy that, in the circumstances she was in, she had her domain, independent of her relations with her husband and Vronsky. That domain was her son . . . Let her husband disgrace her and turn her out, let Vronsky grow cool towards her and continue to lead his independent life (again she thought of him with bitterness and reproach), she could not desert her son. She had a goal in life.
Where lover and son were the incompatibly doubled pairing, now husband and lover are the ill-matched equivalents in Anna’s distorting mental syntax. It is as clear at the outset of her story as at its tragic end that Anna’s psychic machinery is constantly trying to outrun its own primary pain, recreating internal chaos as a result. This is the syntax of a mind which habitually substitutes what is without for what is within: people – husband, lover, son, surrogate daughter – in place of pain. Still, what pain?
Tolstoy, p. .
Tolstoy, p. .
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Literary Realism and Mental Breakdown
As Anna’s example saved Olga in lieu, as it were, of an analyst, so Olga is a touchstone for diagnosing Anna’s pain: ‘If I were to say what suffering is [for Olga],’ writes Ferrante, ‘I would say only: it’s looking at frantumaglia, the jumble of fragments inside.’ In her collection of personal writings of the same name, Ferrante explains that: ‘Frantumaglia’ (a word inherited from her Neapolitan mother) denotes ‘a malaise that could not be defined otherwise, a crowded, heterogeneous mix of things’. ‘It is an effect of the sense of loss, when we’re sure that everything that seems to us stable, lasting, an anchor for our life, will soon join that landscape of debris that we seem to see.’ In Ferrante’s novel, the equivalent term, one which is ‘central’ to the book, is ‘absence of sense’. It is the reason Mario gives for abandoning Olga at the opening of the novel. At the close, it is Olga’s means of separating herself finally from him: To justify yourself, you said that you had fallen into a void, an absence of sense, and it wasn’t true . . . Now I know what an absence of sense is . . . You, you don’t know. At most you glanced down, you got frightened and you plugged up the hole with Carla’s body.
In a wonderful turnaround, it is Mario, not Olga, who turns out to ‘be’ Anna, in thus evasively taking a lover in place of confronting the pain of emptiness. It is Olga who inhabits Anna’s void in place of Anna herself. Olga avoids the more catastrophic breakdown Bion describes, and Anna suffers, of not feeling one’s own pain, only by struggling to the very ‘limit of the bearable’ even so. When she is finally able to ‘take hold’ of herself again – her eyes fall on the still open notebook – on the sentences underlined in red: ‘“Where am I? What am I doing? Why?” . . . Such tensions without sense push us to formulate questions of meaning.’ The latter sentence signals the ‘push’ beyond the reactive ‘why’ to the more profound matter of where that question originates. Born of her precarious capacity at this juncture to bear to inhabit the tension of not having answers, this sentence is what finally separates Olga from Anna. In fact, this modern European woman, so perilously close to being Anna, is nearer at this moment to Tolstoy’s nineteenth-century aristocratic landowner-farmer, Konstantin Levin, who, in Book Eight of Anna
Ferrante, Frantumaglia, p. . Ferrante, Frantumaglia, p. . Ferrante, Frantumaglia, p. . Ferrante, Frantumaglia, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. . Toleration, as opposed to evasion, of frustration, is central to Bion’s theory of healthy psychic life. See Wilfred R. Bion, Learning from Experience (London: Maresfield Library, ), pp. –.
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Karenina, is pushed by his own involuntary impulse toward suicide – ‘not knowing and not seeing any possibility of knowing what he was and why he was living in the world’ – precisely to seek ‘meaning’.
Literary Realism and ‘Containment’ I draw out these more surprising connections and comparisons not for their own sake but to try to evince the added value that literary realism brings as a record of psychic suffering. Such connections – including the one Olga subconsciously intuits between herself and Anna – are not visible from outside or above, as it were, by viewing the bare contours of each ‘case history’ for the purposes of diagnosis. The resonance and affinity (neither predictable nor necessary) between these stories emerges from the close ‘living in’ vis-à-vis the individual and particularized human instance (here of pain and suffering) which is realism’s métier, and which does not permit of crass or premature generalization. The recognition that, as Thomas Nagel puts it, ‘life is always the life of a particular person, and cannot be lived sub specie aeternitatis’ is the rigorous discipline within which realism operates. It is precisely why realism offers both a challenge and a vital corrective to theoretical accounts (medical, therapeutic or other) of psychic sickness. It would be all too easy, for example, to identify what is ‘wrong’ with each heroine on the evidence of the novel, and the historical position and world view of the author. Tolstoy’s solution to the absence of sense is finally a religious one. Anna is lost because the meaning which Levin ultimately finds in God is one which Anna does not even look for (‘the thought of seeking comfort in religion was . . . foreign to her’). Ferrante sees Olga’s suffering as essentially Kleinian at root. For women, every love relationship is a ‘reactivation of the primitive bond with the mother’ and it is this ‘above all that makes the abandonment so devastating’. But literary realism is determinedly ignorant of system and theory. Realism’s gift to the human record of individual suffering is that it puts experience before explanations. Tolstoy famously said of Anna Karenina: ‘If I were to try to say in words everything that I intended to express in my novel, I would have to write the same novel I wrote from the beginning.’ Ferrante ‘hate[s] all the cliches of analysis’ and ‘avoid[s] the slightest
Tolstoy, p. . Thomas Nagel, Mortal Questions (Cambridge: Cambridge University Press, ), p. . Ferrante, Frantumaglia, p. . Tolstoy’s Letters, vols., ed. and trans. by R. F. Christian (London: Athlone Press, ), vol. , p. .
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Literary Realism and Mental Breakdown
allusion to formulas’. She notes: ‘When we tell a story, the only thing that should matter is to find a cascade of our words that will flood all the marked-out territory with the persistence – even if devastating – of a mucilage.’ The value of the genre is that its generous reality can capaciously contain metaphysical and psychoanalytic dimensions, as readily as it incorporates social and domestic levels, within its life. Nothing is excluded in realism’s observation and accounting of suffering. Realist fiction is pre-eminently the genre which exhibits the characteristic of novelistic discourse to ‘not fit’ pre-ordained scaffolding but to operate in ceaseless, dynamic ‘intimate interaction’ with ‘living’ frames and forms, inclusively embracing a totality that is finally amorphous and non-codifiable. Thus, while realism, as Anchor says, ‘cannot present, as we cannot live, in a wholly meaningless world’ – cannot fail in being loyal to the ‘necessary facts’, as Ferrante terms it – realism can and does, in the novels examined here, contain inside it the very forces which threaten meaning. Alongside, within, behind or beneath ‘the facts of reality’, there is the reality of the ‘void’, the ‘vertigo’ of lost meaning, and the recognition that all structure is vulnerable to breakdown. With its roots in a pre-Freudian tradition, realism’s plurality is an important counter to post-Freudian psychopathologizing of human despair, if only in reminding of its un-extraordinariness, its near-inevitability. Above all, however, literary realism toughly offers no cure. Its immersed witnessing of the intractable and un-‘caged’ in ordinary existence is delivered without expectation of coherence and remedy. Olga’s primary suffering of her pain does not expunge it. Olga emerges from breakdown with a language and disposition reminiscent still, almost shockingly, of Anna’s avoidance: ‘Avoid surrendering to the senselessness of the day, hold the fragments of life together as if they still had their allotted place in a design.’ ‘The essential thing was that the string, the weave that now supported me should hold.’ As realism’s metaphysic is wholly aligned with the essential, continuous, ongoing, and ordinary human task of holding life meaningfully together, so it cannot afford, but also does not require, the absolute primal truths or the ultimate solutions of psychoanalysis, with its stable distinctions between primary authenticity and second-order coping. Realism has more respect than the psychoanalytic narrative ever can for the string, the weave, the support, the holding,
Ferrante, Frantumaglia, p. . Ferrante, Abandonment, p. . Ferrante, Abandonment, p. .
Ferrante, Frantumaglia, p. . Ferrante, Abandonment, p.
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Bakhtin, p. .
because that is realism’s stock-in-trade. Olga finds in Tolstoy’s novel not an answer but questions, and, after all, a relativist metaphysic that saves her: ‘Existence is this, I thought, a start of joy, a stab of pain, an intense pleasure, veins that pulse under the skin, there is no other truth to tell.’ Realism’s endemic resistance to redemptive outcomes is a further fierce test and provocation to modern therapeutic orientations, as well as to the uses of realist literature within therapeutic practices and medical humanities for its supposedly benign models of suffering finally vanquished. Still, my purpose in this chapter is not to oppose literary realism to psychoanalysis but to suggest how one might act as an adjunct, or help serve the purposes, of the other. Olga provides a practical model of how this might happen. An ordinary woman in mid-life, undergoing an experience common enough to her (middle-class, educated) sociocultural circle, finds herself at a critical point of her psychic crisis, turning involuntarily to a nineteenth-century realist novel. What Olga finds there is not the safe consolation of a representation of real life more ordered than her own – not the ‘fantasies of realism’ which, said Lyotard, in order ‘to deceive, to seduce and to reassure’, necessarily ‘avoid the question of reality’. On the contrary, in Anna’s own vertiginous voicing of despair, Olga confronts reality itself, the ‘ultimate reality, the absolute truth’ which, for Bion, was the object of psychoanalysis and indeed constituted the psychoanalytic event. This is the ‘really real’, ‘the thing-in-itself’ which Anna’s own mental contortions sought to evade of course. But it is a reality which no human frame could ‘bear much of’, said the realist novelist George Eliot. Indeed, she wrote in Middlemarch (a foundational novel in the nineteenth-century realist tradition), if we had ‘a keen vision and feeling’ for that reality, we should ‘die’ of it – as Olga almost feels she will (‘everything was slipping away . . . I was lost’) – not least because the customary forms of ordinary life fail adequately to realize or represent this reality. This is why Bion designates this reality, ‘’, in recognition that it is inimical to conventional formulation or containment. It is why the ending of Ferrante’s novel draws attention to the relative fiction of literal real life (‘Every movement could be narrated with all its
Ferrante, Abandonment, pp. –. I enlarge on this idea at length in Is Literature Healthy? pp. –. Lyotard, pp. –. Wilfred R. Bion, Attention and Interpretation (London: Maresfield Library, ), p. . Bion, Attention and Interpretation, p. . George Eliot, Middlemarch, ed. by David Carroll (Oxford: Oxford University Press, ), p. . Eliot, p. . Eliot, p. . Ferrante, Abandonment, p. . Bion, Attention and Interpretation, p. .
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Literary Realism and Mental Breakdown
reasons good or bad [in the] return to the solidity of the links that bind together spaces and times . . . I pretended to believe . . .’), while the author insists, as we have seen, that the literary representation of real life ‘orchestrate[s] lies that always, strictly, tell the truth’. Realism’s singular achievement is to make realizable and bearable, and above all available, forms of reality which real life itself ordinarily (and protectively) conceals. But, importantly, it does so without suspicious or sceptical distortion of the mundane structures which hold together a life (Olga’s response is unironic ‘gratitude’ for the ability to ‘sew up around me a world that could be trusted’); without minimizing breakdown’s power to destroy those structures; and while registering and making shareable how riskily susceptible the most common and ordinary life is to involuntary rupture and reshaping.
Ferrante, Abandonment, pp. –. Ferrante, Abandonment, p. .
Ferrante, Frantumaglia, p. .
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Time and Narrative in the Age of Postnatural Death Maylis de Kerangal’s The Heart Jared Stark
. . . time becomes human time to the extent that it is organized after the manner of a narrative . . .
– Paul Ricoeur, Time and Narrative
The leaden circles dissolved in the air.
– Virginia Woolf, Mrs Dalloway
What difference does it make that my driver’s licence, the one issued to me by the State of Florida in the US but that has its analogues in other jurisdictions, has blazoned on its front the symbol of a heart, in red, followed by the word ‘donor’? When I made the decision that led to the imprint of the symbolic heart on my licence, I was perhaps quite deliberate in trying to imagine its consequences. Perhaps it was a memorable and momentous decision in which the whole shape of a possible life was imagined and affirmed. Or perhaps the decision was taken more unthinkingly, in the midst of other concerns or in the fog of bureaucratic processes, a moment absent from conscious memory. Perhaps I did not even try to imagine its meaning. Or perhaps I was incapable of so doing, for how could I possibly imagine myself across the divide of the kind of events that would set into motion the consequences of that decision? Perhaps, even, such a decision would have been taken out of my hands, if I were a citizen of one of many countries where consent is presumed or where it would have fallen upon me explicitly to refuse the future transplantation of my organs, as in much of Europe and Scandinavia, that is, in what are often called opt-out nations as compared to the opt-in systems in place in the US, the UK, Canada, and elsewhere. For presumably, at the moment when it becomes a question of obtaining vital organs from the one identified on the face of the licence, the one of whom it cannot simply be said that it is ‘my’ body that is at issue – presumably, at that time, the one who now depends on those organs will no longer need them. ‘I’ will not be there, due to an irremediable finitude or perhaps passage into a
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Time and Narrative in the Age of Postnatural Death
condition in which I am no longer dependent on my biological body, in which existence is otherwise. But when will that be? At what moment in time will my death have taken place? The questions raised by the symbolic heart instantiate what literary scholar and bioethicist Rosemarie Garland-Thomson names as a pervasive and overdetermined ‘medical subjectivity’, in which ‘[m]edical science understands us and treats us according to its logic and practices’. Medical logic in this instance figures my death as the potential availability of biomaterial, while at the same time understanding me and inviting me to understand myself as a potential organ recipient. In so doing, it also implicates me in a medicolegal understanding of death that emerges historically with the advent of organ transplant techniques. As anthropologist Margaret Lock explains: Particularly after the world’s first heart transplant in , many recognized that doomed patients on life support represented potential organ sources. However, these patients could not be diagnosed as dead in the usual way because their hearts were still beating, sustained by the ventilator. Doctors urgently needed to be able to formally declare death so that organs could be removed from brain-dead patients without legal repercussions. A new definition for death had to be established, one that located death in the brain; and its criteria needed to be uniform and objective.
To opt in to, or to fail or decline to opt out of, a system of organ procurement and transplantation means, then, to participate in what Lock calls the ‘reinvention of death’ as brain death. However else one may face (or fail to face) mortality, the medical logic that shapes medical subjectivity defines death as the cessation of certain brain functions as determined according to certain diagnostic tests.
Rosemarie Garland-Thomson, ‘Disability Bioethics: From Theory to Practice’, Kennedy Institute of Ethics Journal, , (June ), – (p. ). Here, as in my earlier work A Death of One’s Own: Literature, Law, and the Right to Die (Evanston: Northwestern University Press, ), I foreground the role of law in medical bioethics, as legal frameworks increasingly come to permeate medical decision-making. While a fuller discussion of this methodological emphasis is beyond the scope of this chapter, we might take as exemplary Tod Chambers’s argument, with respect to one particular clinical situation, that ‘at present, the ritual act of informed consent transforms the patient-physician interaction into a legal relationship rather than a therapeutic one’, in ‘The Rites of Bioethics’, in Health Humanities Reader, ed. by Therese Jones and others (New Brunswick: Rutgers University Press, ). Ebook. Margaret Lock, Twice Dead: Organ Transplants and the Reinvention of Death (Berkeley: University of California Press, ), p. . As bioethicist Arthur Caplan observes, the criteria can indeed vary significantly. Citing one dramatic example, he writes: ‘A person can be declared dead in Hungary, the body can be driven across the border to Slovakia, and, under the different medicolegal criteria for being dead that prevail there, the person can return to life.’ ‘Death: An Evolving, Normative Concept’, in Defining Death: Organ
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Bioethical scholarship and debate have crucially and persistently raised questions concerning this reinvention of death. Are the criteria and tests that define and ascertain brain death fully valid – is brain death, in other words, really death? How can we understand the temporal gap between the cessation of cerebral function and the cessation of respiration, circulation, or cardiac function, particularly when certain biological functions can be sustained mechanically? What rights or responsibilities, if any, belong to a potential donor, or recipient? As much as medical, legal, and principlebased bioethical discourses may acknowledge fundamental uncertainties, they operate largely within the horizon of problem-solving, seeking to contain or regulate uncertainty and ambiguity in order to establish and regulate clinically, legally, economically, and morally acceptable practice. In this chapter, as elsewhere in my work, I understand the relationship between bioethics and literature as mutually informing. While literature necessarily reflects and absorbs the logics and practices that structure medical subjectivity, it can also defamiliarize what tend to become, all too quickly, its accepted and self-limiting vocabularies. Polarized debates concerning the right to die, the focus of my earlier work, generally remain indebted to conventional conceptions of death. Consequently, they are unable to take into account the conditions that give rise to those debates in the first place – namely, the advent of what I have called ‘postnatural death’. Death becomes postnatural when what once may have appeared or been imagined as a ‘natural’ or ‘proper’ death does not take place when it seemed like it should. Displaced by life-prolonging and resuscitation technologies that manipulate the time of death, the proper time for ‘natural’ death withdraws, becomes indiscernible. Organ transplantation, like the issue of the right to die, evidences the advent of postnatural death. Where bioethical discussion tends to focus, then, on whether, or in what conditions, transplantation can be an ethically legitimate practice, literature, for its part, can both deepen and reframe the questions that animate bioethical discussion by inviting readers to dwell in the ambiguities and
Transplantation and the Fifty-Year Legacy of the Harvard Report on Brain Death, Hastings Center Special Report ed. by Robert D. Truog and others, Hastings Center Report, , S (), S–S (p. S). For a useful overview of these debates, see Defining Death. Stark, A Death of One’s Own. For earlier but still relevant reflections on bioethics and literature, with particular attention to the possible roles of literature in bioethics pedagogy, see the special issue of Literature and Medicine, () devoted to ‘Literature and Bioethics’, as well as Howard Brody’s discussion of narrative bioethics in chapters – of Stories of Sickness, nd edn (Oxford: Oxford University Press, ). Stark, A Death of One’s Own, p. and passim.
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Time and Narrative in the Age of Postnatural Death
contingencies that medicolegal logic and practices necessarily seek to resolve. Works of literature can serve as what Maren Tova Linett calls ‘literary-ethical laboratories’. Whereas bioethics, particularly as bioethical issues become encoded in law and regulatory policy, relies on convention and precedent, the literary imagination may provide different and complementary resources with which to encounter the newness and strangeness of the time of postnatural death. It is largely due to the development of organ transplant technologies that, in medicine and the law, the time of death has acquired vital importance. As legal scholars Seema Shah and Franklin Miller observe: ‘With few exceptions, the traditional legal consequences of death did not require determining the moment of death with precision.’ The possibility of organ donation changes this picture, for ‘it was only when death became a prerequisite for vital organ donation that it began to matter exactly when a person died’ – down, indeed, to the very minute or second. Ascertaining a precise time of death matters, moreover, not only for a medical system concerned with conserving viable vital, transplantable organs. It also, as Marcela Iacub notes, marks a radical transformation in legal status, ‘removing from human beings the status of rightsbearing subject’. Bioethical discourse tends to organize itself into two opposed camps. On one side are those who oppose the reinvention of death as brain death altogether, although the reasons for this opposition can diverge widely. On the other side are those who seek to legitimize and stabilize the concept of brain death, though again in myriad ways, whether by attempting to increase scientific precision, or, acknowledging the limits of medical science, by conceiving of practical juridical and moral criteria. In this chapter, I explore how this reinvention of death carries not only clinical and legal but also narrative significance, particularly for the ways that narrative may shape the understanding and experience of time. Walter Benjamin encapsulates a narrative theorem in observing that: ‘A man . . . who died
Maren Tova Linett, Literary Bioethics: Animality: Disability, and the Human (New York: New York University Press, ), p. . Seema K. Shah and Franklin D. Miller, ‘Can We Handle the Truth? Legal Fictions in the Determination of Death’, American Journal of Law & Medicine, , (), – (p. ). Shah and Miller, p. . Marcela Iacub, ‘La construction de la mort en droit française’, Enquête, (), – (para. ) . Translation mine. Paul Ricœur notably offers compelling philosophical evidence of this claim in his three-volume Time and Narrative, trans. by Kathleen (McLaughlin) Blamey and David Pellauer (Chicago: The University of Chicago Press, –).
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at thirty-five will appear to remembrance at every point in his life as a man who dies at the age of thirty-five.’ The time of death gives narrative shape and meaning to a life, and as such makes meaningful narrative possible. As Benjamin writes, ‘[d]eath is the sanction for everything that the storyteller can tell. He has borrowed his authority from death.’ In this light, we might ask about the consequences for narrative meaning of a newly medicalized definition of the time of death. What does it mean to tell the story not only of a man who dies at the age of thirty-five but of a man who dies at a precise minute as determined by the protocols and requirements of medical authority? This question, on the one hand, points to the ways that medicine, in defining the time of death according to seemingly objective technical knowledge and practices, materially shapes the ways in which narrative confers or discovers meaning. Medicine determines, to borrow Frank Kermode’s phrase, the sense of an ending. On the other hand, as we will see, the medical reinvention of death introduces or exposes an inherent uncertainty within the concept of death. The declaration of the time of death, as Shah and Miller argue, remains essentially a ‘legal fiction’, in which ‘the determination of death has been modified to fit our current practices’. Patients whose deaths remain questionable are consequently treated ‘as if they were dead’. While the medicolegal determination of death as brain death transforms me from living subject and bearer of rights into biomaterial, the fictionality of this legal determination suggests that it remains shadowed by inherent gaps between, on the one hand, the certainty required by medicine and the law and, on the other, the uncertainties and alternative temporalities that hover irreducibly around any death.
A Revolution in Time ‘The heart is dead, long live the brain – a symbolic coup d’état, a Revolution.’ This thought is attributed to the critical care physician
Walter Benjamin, ‘The Storyteller: Observations on the Works of Nikolai Leskov’, trans. by Harry Zohn, in Walter Benjamin, Selected Writings, Vol. , –, ed. by Howard Eiland and Michael W. Jennings (Cambridge, MA: Belknap Press, ), pp. – (p. ). Benjamin, p. . Frank Kermode, The Sense of an Ending: Studies in the Theory of Fiction (Oxford: Oxford University Press, ). Shah and Miller, p. . Shah and Miller, p. . Maylis de Kerangal, The Heart, trans. by Sam Taylor (New York: Picador, ). Further references are given after quotations in the text. Where given, quotations from the French original refer to
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Time and Narrative in the Age of Postnatural Death
Pierre Révol in Maylis de Kerangal’s novel, Réparer les vivants. In , the novel was adapted for the screen by Katell Quillévéré and published in a British translation by Jessica Moore as Mend the Living. The following year, the novel received the Wellcome Book Prize, awarded to ‘the best books illuminating some aspect of medicine, health or illness’, and appeared as well in a new American translation by Sam Taylor, with the title The Heart. Mediated by an omniscient narrator, each chapter of the novel centers on a different actor involved in a heart transplant. In the first chapter, -year-old Simon Limbres is involved in a car accident returning from an early morning surfing session – an accident that is rendered particularly poignant in that it follows an experience of temporal transcendence, where ‘time no longer exists – there is no history here, only the randomness of the waves that buoy and whirl him’ (). Subsequent chapters move from Simon’s parents and girlfriend, to various members of the medical staff and biomedical agency participating in the transplant process, to the -year-old Claire Méjan, the recipient of the transplanted heart. I turn to de Kerangal’s novel as an exploration of the narrative consequences of, as well as a narrative challenge to, the medicalized temporality of brain death. For, as Rishi Goyal writes, ‘time is the central protagonist in this novel’. Along with the work of the other contemporary French writers who, with de Kerangal, form the Inculte Collective, The Heart operates partly in documentary mode. This appears, most notably, in the deeply specialized vocabulary it employs to depict the medical and bureaucratic process of a heart transplant with what reviewers gleefully called ‘surgical precision’. Nonetheless, the novel, in its resonant poetic and formal aspects, does not serve simply as a naturalistic account of the
Maylis de Kerangal, Réparer les vivants, Folio edition (Paris: Gallimard, ), and are preceded by RV. Wellcome Book Prize [accessed February ]. As there are some significant differences between the American (Taylor) and British (Moore) translations, in citing the novel in English I refer to the American translation and refer to it by the American title, The Heart. Rishi Goyal, ‘“The Mind Lives on the Heart”: A Death Deferred’, Los Angeles Review of Books, March [accessed August ]. Bernard Pivot, ‘Maylis de Kerangal: le cœur nomade’, Le Journal du Dimanche, January [accessed August ]. On the role of ‘thick description’ and de Kerangal’s efforts to ‘expand her linguistic palette’ by incorporating technical language, see Laurent Demanze, ‘Gestes anthrolopologiques de Maylis de Kerangal’, Études françaises, , (), – (p. ).
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medical world. Rather, as Alison James observes of the Inculte Collective as a whole, de Kerangal’s novel stages ‘a productive rivalry between fiction and the real’. Whereas it is often the case in the broad field of medical humanities that literature, or the humanities more broadly, is enlisted as a humanizing influence on medicine, The Heart, in this light, provides the opportunity not only to see medicine through the lens of the literary imagination, but also to discover how medicine might reveal something about fiction. What Révol perceives as a revolution in the definition of death is thus an event that the novel not only documents but also defamiliarizes, making apparent two defining characteristics of medical temporality that I discuss here: first, synchronization, that is, a submission to and regulation by the authority of chronological time, and second, irreversibility, that is, an allegiance to the unidirectionality of time’s arrow. Révol, as his very name suggests, is a veritable child of the ‘révolution’ that produces this temporality, born as he is in , the same year as the prized back issue of Revue neurologique that, the reader learns, sits on his office bookshelf. In this journal, French physicians Maurice Goulon and Pierre Mollaret published their pioneering study defining the state of coma dépassé, in which cardiac and respiratory functions may persist and be sustained with aid from a mechanical ventilator but where no cerebral activity is detected, as a state of death. Révol’s name and birth year bind his life and work to the medical temporality – what we might call the revolutionary calendar – produced by the reinvention of death as brain death. The first aspect of this temporality becomes apparent as Révol notifies the organ donation coordinator, the memorable Thomas Rémige, that there is a patient ‘in a state of brain death’ (en état de mort encéphalique) (, RV ): I’ve requested the first EEG, they’re doing it now – words that are like the pistol shot at the start of a race, because, by ordering this exam, Révol has triggered the legal procedure for recording the death of this young man. There are two kinds of protocol for this: either a CT angiography (or, in the event of brain death, a scan confirming the absence of intracranial blood flow) or two thirty-minute EEGs, carried out at four-hour intervals, showing the flat line that signifies the disappearance of all cerebral activity. ()
Alison James, The Documentary Imagination in Twentieth-Century French Literature: Writing with Facts (Oxford: Oxford University Press, ), p. .
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Time and Narrative in the Age of Postnatural Death
The need to determine a precise time of death, required for organ transplantation, sets in motion a medical temporality structured by precise, synchronized clock time. For Rémige, too, this notification launches ‘a high-precision movement that must be unfolded in accordance with a very specific time line, which is why he now looks at his watch – something he will do many times in the hours that follow, something they will all do, repeatedly, endlessly, until it is all over’ (). The exigencies of the medical stopwatch suffuse the consciousness and decisions of the members of the medical team and biomedical agency in a series of carefully noted time markers. The notification from the ambulance squad to Révol: ‘A call at : a.m.’ (). Révol recording Simon’s death on his computer: ‘It is : a.m.’ (). His first encounter with Simon’s mother: ‘He glances at his watch – :’ (). His ‘microsiestas’: ‘the doctor will gravitate to that rolling, swaying chair of his, check his watch, start a countdown – three minutes, the time it takes to boil an egg: the perfect measurement’ (). The moment when Simon’s parents consent to the donation: ‘It is : p.m.’ (). The timing of the EEGs: ‘: p.m., when the second EEG will be completed, marking the legal time of Simon’s death’ (). The official notification to the doctor responsible for organ allocation at the Biomedical Agency: ‘the official report of Simon Limbres’s death, filed at : p.m.’ (). The allocation coordinator’s acute awareness that ‘there must be a maximum of four hours between the moment when the heart is stopped inside the donor’s body and the moment when it is restarted in the recipient’s body’ (). And then the stages of the transplantation process: ‘The organ-removal teams begin arriving at : p.m.’ (). Rémige noting ‘the time when the aorta was clamped – : p.m. – a figure that instantly sharpens the timeline for the coming operation: prepping the recipient, transporting the organ, transplanting the organ’ (). At midnight, in Paris, preparing Claire in the OR to receive the heart – ‘And so it begins, like the start of a race’ – while in Le Havre the heart transplant team is fixated on time as they travel from the hospital in Le Havre to the private plane waiting to return them to Paris: ‘The vehicle speeds through darkness while they watch the movement of figures on the dashboard clock’ (). The landing of the plane – ‘The plane lands at Bourget at : a.m. Time is radicalized’ (; trans. modified). The moment of tension when the medical transport hits an unexpected traffic jam, and the driver’s deft manoeuvres: ‘The vehicle stops in front of the building – thirty-two minutes, not bad’ (). Meanwhile, in Le Havre, the removal of the last organs destined for transplant, the kidneys, from Simon’s body: ‘At : a.m.’ (). Then
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the reactivation of Simon’s heart once it has been sutured into Claire’s body ‘at four in the morning’ (), the cleaning of the operating room, and the surgical team removing their scrubs as the novel marks time one last time in its final words: ‘it is : a.m.’ (). As this list of moments illustrates, The Heart does not only chronicle the role of synchronization in regulating medical temporality, it also evinces a fascination with the time pressure produced by this regime. Like Rémige, the novel, too, is always looking at its watch, such that clock time gives the novel its very plot structure. For as we read the last words, we are thrown back to the first chapter, where a mobile phone alarm awakened Simon for his morning surfing session – ‘the echo of a sonar signal translated into luminescent digits on the touchscreen – :’ (). The rule of the clock gives the novel its perfect twenty-four-hour time frame. The second organizing principle of medical temporality is named as Révol describes Simon’s condition to his mother using a term with specific consequence in medicolegal terminology but without explaining its significance: ‘Ah, she says, so how is Simon’s condition developing exactly? In speaking like this, she knows she is leaving herself open to another blow, that she is taking a risk. Révol inhales deeply before replying. Simon’s injuries are irreversible’ (). Révol here uses the precise vocabulary of the French law that codifies brain death as legal death, which requires the ‘irreversible character of encephalic activity’ in order for someone to be declared legally dead prior to organ procurement. French law here parallels the US Uniform Determination of Death Act, which defines death as ‘. Irreversible cessation of circulatory and respiratory functions; or . Irreversible cessation of all functions of the entire brain, including the brain stem.’ The same criterion of irreversibility holds in the UK, as articulated in the Academy of Royal Medical Colleges’ ‘A Code of Practice for the Diagnosis and Confirmation of Death’ and its update. Along with the fixation on clock time, the claim to irreversibility figures medical temporality as unidirectional and as such incontestable. Synchronicity and irreversibility thus work together to provide medicine with a sense of mastery, with the power to both determine the precise moment death takes place and to defer death through medical
Qtd. in Iacub, para. . Translation mine. National Conference of Commissioners on Uniform State Laws, ‘Uniform Determination of Death Act’ (), §. Not encoded in civil law, but in medical standards recognized by the law.
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interventions. This medical temporality also imposes a certain story on Simon, determining the ways his body is absorbed into medical practice. To the doctor responsible for organ allocation, he is a ‘Cristal [database] file . . . a medical evaluation of each organ, scans, ultrasounds, other analyses’ and ‘an identification number, a code that will guarantee the donor’s anonymity’ (). To the cardiac surgeon sent from Paris to Le Havre, he is a series of abstractions: ‘a magnificent heart’ () and ‘the possibility of life’ (). To Claire, the recipient, despite her queries, the anonymizing biomedical protocols mean that he will remain but a location, ‘Seine-Maritime’, and a sex, ‘Male’ (). To Thomas Rémige, the transplant coordinator in Le Havre who will prepare Simon’s body to be returned to his parents, he is ‘the donor’ (), ‘a corpse’ (), a body ‘fragmented and divided by life’ (). In these figurations, Simon appears as a specimen, biomaterial, or medical potentiality, rather than a singular individual. In this light, as the transplant team concludes its work and one of the cardiac surgeons invites an observing medical student ‘to join him for a beer somewhere in Montparnasse, for a plate of fries and a bloody steak’ (), the -hour cycle of the novel comes to appear as the sign of an ordinary day, of a job well done, of the absorption of death into medical routine. It is as if in the minute after :, another youth will awaken, another car accident will take place. Another day, another heart.
Counterrevolutions Even as The Heart lays bare the determinants of medical temporality, it both questions the legitimacy of medical time, which I explore in this section, and proposes a mythographic alternative, to which I turn in the last part of this chapter. At least one way in which the legitimacy of the medical temporality of death comes into question is in the novel’s focus on the historicity of this temporality itself, as signalled by the other books, in addition to the medical journal, that are found in Révol’s office: Philippe Ariès’s classic history of cultural attitudes towards death in Western Europe, L’homme devant la mort (The Hour of Our Death); immunologist Jean Claude Ameisen’s revelatory La sculpture du vivant: le suicide cellulaire ou la mort créatrice (The Sculpture of the Living: Cellular Suicide or the Creative Death), which understands life and death as continuous processes that take place at the cellular level rather than as attributes of the human organism as a whole; the aforementioned anthropological study by Margaret Lock, Twice Dead: Organ Transplants and the Reinvention of Death, which demonstrates the cultural
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idiosyncrasy of the rapid acceptance of the brain death standard in Europe and North America by contrast with Japan; and Mary Higgins Clark’s thriller, Moonlight Becomes You, which Révol values for its evocation of the Victorian fear of premature burial and the fad for safety coffins equipped with air tubes and alarm bells attached by a cord to the finger of their occupants. In raising the possibility that the decisive moments that organize medical synchrony may themselves be the attribute of a particular cultural moment, this history of death impedes and interrupts the regulated synchronization of medical time. Simon’s parents, for instance, confront Révol with a view of death that remains out of sync with the medical definition of brain death: ‘How could they even think about the death of their child when what was a pure absolute – death, the purest absolute of all – had been reformulated, newly defined, in different bodily conditions?’ (). Likewise, when Sean asks Rémige why they are ‘keeping [Simon] alive if there is no hope’, his very vocabulary – he refers to Simon as ‘alive’ – troubles the medical logic that defines him as already dead and interrupts medical time: his questions ‘sever the usual chronology of the protocol’ (). It is therefore no surprise that Sean’s questions trigger the second mention of Clark’s novel and its allusion to an earlier historical period, as Révol and Rémige sense in Sean’s questions ‘the visible tip of an iceberg of ancient terror: being declared dead, by doctors, when you are still alive’ () – a terror nurtured not only by Clark but by a longer literary tradition, with Edgar Allen Poe’s ‘The Premature Burial’ as indelible locus classicus. Révol and Rémige predictably attempt to reassure Simon’s parents of the procedures meant to guarantee the disinterestedness and accuracy of a declaration of brain death. The novel, however, subtly legitimates this fear of premature burial when it refers to ‘[t]he definitions of the various criteria for death developed in order to allow organ removals’ (). For in this ‘in order to’ (afin de), the novel assumes a position in the controversy over whether brain death standards were established independently of a vested interest in organ transplantation, or whether instead, as the novel implies, echoing Lock and others, brain death criteria serve primarily and troublingly to create a source of viable vital organs for transplantation. Despite the procedural safeguards that Révol and
For an overview of the theme of premature burials in literature, see Jan Bondeson, Buried Alive: The Terrifying History of Our Most Primal Fear (New York: Norton, ), pp. –. For the first argument, see Calixto Machado and others, ‘The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants’, Journal of Medical Ethics, , (April ), –, and
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Rémige describe – modern-day equivalents of the Victorian safety coffin – at the same time their work is shadowed by a history of suspicion surrounding the disinterestedness and thus the validity of medical diagnoses that a death-like state is irreversible. The legitimacy of irreversibility as medical criterion is also called in question in the novel’s rendering of Simon’s mother’s experience. After Révol first uses this medicolegal term to refer to Simon’s condition, it haunts her, even though she seems unaware of its decisive role in the medicolegal determination of death. Before informing Sean of their son’s diagnosis, she meditates on the word itself: The situation is irreversible – she swallows as she thinks of this word she must pronounce, ‘irreversible’, five syllables that freeze the state of affairs forever, a word she never utters, because she believes in the continual movement of life, the possibility of turning any situation around, nothing is irreversible, nothing, she proclaims at every opportunity – speaking the words in a lighthearted tone, gently shaking the words, the way she would the shoulders of someone who’s feeling down, nothing is irreversible, apart from death, or disability, and maybe then she might spin around, begin dancing. But Simon . . . no. Simon is irreversible. ()
As Marianne displaces Révol’s word from its medicolegal context and discovers it in lay expressions and situations, the novel registers the violence inscribed in the medicolegal jargon. Where the physician renders the body as clinical object in speaking technically of irreversible injuries, Marianne estranges the word ‘irreversible’ by applying it to Simon himself, where irreversibility now stands for his singularity, for his permanence in her life and memory. If irreversibility names temporal unidirectionality in its medicolegal usage, it acquires a different temporality in Marianne’s memory, in her idiolect, as she later recalls her reactions to Simon getting a tattoo: ‘Simon was so young, she said anxiously, this tattoo of yours, you do realize it’s for life? And the word comes back at her, like a boomerang: “irreversible”’ (). ‘Like a boomerang’, irreversibility comes, paradoxically, to name reversibility itself. As the novel troubles the medical temporality of irreversibility, it also invites a re-evaluation of its medico-technical meaning. For if irreversibility serves as the very criterion that transforms a living human into biomaterial, if it pronounces legal death, medical and philosophical debate has Gary Belkin, ‘A Path Not Taken: Beecher, Brain Death, and the Aims of Medicine’, in Defining Death, ed. by Truog and others, S–S.
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repeatedly confronted the problems inherent in this criterion. As neurologist James Bernat notes, the medicolegal meaning of irreversibility requires careful parsing, particularly in contrast with its nearsynonym, ‘permanent’. ‘Irreversible’ has acquired the medicolegal meaning of a condition that ‘cannot possibly be regained spontaneously or restored through intervention using any available technology’. A ‘permanent’ condition, by contrast, may be so because ‘physicians will not [but potentially could] attempt resuscitation or use other means to restore it’. In sum, ‘[a]ll functions that are irreversibly lost are also permanently lost (but not vice versa).’ What separates ‘irreversible’ from ‘permanent’ in medical usage, in other words, is the agency of medicine itself, where ‘irreversibility’ would name the impossibility of medical resuscitation and ‘permanence’ would admit that possibility. The problem, however, lies in how to determine when a condition that may be but has not been reversed cannot or can no longer be reversed – how to draw the line, that is, between possibility and impossibility. For the only certain and incontestable way to ascertain the irreversible character of cerebral function is through an autopsy, that is, after cardiac death and therefore at a point when the heart and other vital organs are no longer transplantable. The tests that are commonly used to ascertain irreversibility prior to cardiac death and therefore to make a body into an eligible source of transplantable organs irreducibly include ‘a personal judgment suggesting more of a prognostic than a diagnostic procedure, and including an uncertainty that did not exist when death was defined as the cessation of circulation’, Marcela Iacub observes. In this view, ‘irreversibility’ is not a constative description of an objectively ascertainable state, but rather, and troublingly so, a performative utterance that produces the death it claims simply to describe. If we return to the timeline charted earlier, we can see how The Heart witnesses the performativity, and therefore the fragile contingency, of the declaration of legal death. For Simon’s death is registered no fewer than four different times: at : a.m. when Révol notes Simon as dead in his computer but before requisite tests have been performed; following these tests at : p.m.; at : p.m. when the death report is filed; and again at : p.m. when the aorta is clamped and circulation ceases. If each
James L. Bernat, ‘How the Distinction between “Irreversible” and “Permanent” Illuminates Circulatory-Respiratory Death Determination’, Journal of Medicine and Philosophy, , (), – (p. ). Bernat, p. . Iacub, para. . Iacub, para. .
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Time and Narrative in the Age of Postnatural Death
declaration of death might be seen as supplementing or completing the previous declarations, at the same time it shows each of them to have been incomplete and premature. The medical logic of death thus remains or is shown to be irreducibly at odds with what Iacub calls ‘human death’. This appears perhaps most poignantly when Révol attempts to announce Simon’s death to his parents. What he intends as a translation of medical into lay terminology instead touches a limit of translation or even of language itself: Révol talks and talks, as if [comme si] gathering evidence, enumerating facts, pausing after each piece of information, his intonation rising – a way of saying that the bad news is accumulating, piling up over Simon’s body – until finally his sentence comes to an end, exhausted, suddenly indicating the void stretching out before it, like a dissolution of space. Simon is in a state of brain death. He is deceased. He is dead. [Simon est en état de mort cérébrale. Il est décédé. Il est mort. ] (, RV ; trans. modified)
Speaking ‘as if’ gathering evidence, Révol’s language attempts, but also fails, to name and to know death, as in Révol’s stuttering, triple pronouncement of death. Is death a ‘state’, a condition, in which one is suspended (‘en état’)? Is it an event, rendered in a verbal past tense (décédé)? Or is it grammatically ambiguous, caught between the two, as in the phrase, ‘il est mort’, where mort is at once an adjective and a past participle, equally translatable as ‘he died’ and as ‘he is dead’? The attempt to name death in a medically precise language, a language of facts and evidence, ends up exposing a limit to language and knowledge. ‘Death’, as J. Hillis Miller reminds us, ‘is a catachresis for what can never be named properly’. Indeed, as Marianne and Sean are finally permitted to see their son in his hospital room, the inadequacy of the medical logic of death becomes dangerously visible. The mechanical ventilator creates ‘with each inhalation, a small but perceptible movement that makes it look as if he’s asleep’ (). Here, they overhear a nurse softly if distractedly addressing Simon directly, an action for which Révol will later reprimand her: ‘I’m going to take your temperature. She speaks to Simon. Révol freezes. Marianne and Sean stare at her in amazement. The young nurse turns her back to them,
Iacub, p. . J. Hillis Miller, Versions of Pygmalion (Cambridge, MA: Harvard University Press, ), p. . Derrida similarly reminds us that ‘if there is one word that remains absolutely unassignable or unassigning with respect to its thingness, it is the word “death”’ (Jacques Derrida, Aporias, trans. by Thomas Dutoit (Stanford: Stanford University Press, ), p. ).
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all right, that’s good, then checks his blood pressure and says I’m going to look at your catheter now, to see if you’ve peed – she is so gentle, it is almost unbearable’ (). Between ‘sleep and ‘death’, addressability and inaddressability, brain death and cardiopulmonary death, legal and human death, Simon Limbres is thus suspended in the limbo (limbes, in French) as well as the shadowy space (l’ombre) to which his surname alludes.
Healing Time One might also say that Simon is suspended, then, between discrepant temporalities: the synchronized, unidirectional temporality of medicine and another form of temporal revolution that his accident and his inscription into the medical world set in motion. This other revolution is apparent already at the moment when Marianne receives the initial phone call from the hospital and sees her life cinematically: ‘a pan of her life . . . detaches itself from the present, toppling into the past (dans un temps révolu)’ (–, RV ). The “temps révolu” to which Marianne is subject here – a bygone or past time but also more literally time overturned, revolved – reverberates throughout the novel, from the telephone call that ‘broke the continuity of time’ () to the temporal disjunction she experiences when first speaking to Sean across the divide of the knowledge of Simon’s accident, when Sean’s voice sounds ‘suddenly strange, abominably strange, because it comes from a space-time where Simon’s accident never occurred, an intact world light-years away from this empty café’ (). The incompatibility – but also the mutual entanglement – of these two temporalities of death is made explicit in Marianne and Sean’s pivotal encounter with Thomas Rémige, as he seeks their consent to the donation of Simon’s vital organs: Even though they are sharing the same space, however, inhabiting the same time, at that precise moment, nothing in this world could be more distanced than those two beings, in their pain, and this young man who has placed himself before them with the aim – yes, with the aim – of gaining their consent for the removal of their child’s organs. Here are a man and a woman caught in a shockwave, at once thrown into the air and smashed down into a broken temporality (une temporalité disloquée) – a continuity brutally severed by Simon’s death but which, like a headless duck running around the courtyard, keeps going senselessly – a temporality woven from
These resonances are pointed out in Maïté Snauwaert, ‘Maylis de Kerangal: La fabrique du vivre’, Études françaises, , (), – (p. ).
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pain, a man and a woman in whose heads are concentrated the whole tragedy of the world. And here is this young man in a white coat, cautious but committed, determined not to jump the gun, but highly aware of the silent countdown in a corner of his mind, knowing all too well that a body in a state of brain death quickly deteriorates, that time is of the essence – and torn between these two imperatives. (–, RV –)
Viewed from the perspective of the omniscient narrator, both Simon’s parents and the organ transplant coordinator are caught between these two temporalities, and consequently between two stories, one that figures Simon as biomaterial, ‘a body in state of brain death’ and subject to a ‘silent countdown’, and the other roiled in a temporality of illogic and senselessness, as in the image of the headless duck, a time out of joint in which what was thought to be irreversible, death, turns out to have been reversible or not to have been registered, not to have taken place. What appears to be the same, precise moment in time is instead the site of two incompatible narratives, as Sean recognizes: ‘We know, we know all that, transplants save lives, the death of one person can give life to another, but Simon is our son, don’t you understand?’ (). To repair the living, as the original title of the novel has it, would mean, in this light, not simply to save the lives of the beneficiaries of organ transplants. It also means to reconcile medical temporality with the temporality of shock and mourning. It would mean to heal the wound inflicted on time itself, to reconcile two temporalities that ‘inhabit the same time’ and yet remain at odds. Marianne’s experience registers the potential irreconcilability of the two, as she attempts to align her own perspective with the medical gaze: Marianne turns one last time toward the bed and what paralyzes her in that moment is the solitude that emanates from Simon, now as alone as an object, as if he had jettisoned his human essence, as if he were no longer linked to a community, connected to a network of intentions and emotions, but was wandering, lost, metamorphosed into an absolute thing. (–)
The ‘as if’ here might indicate her inability or refusal to ratify the medical subjectivity that figures the brain-dead body as ‘an absolute thing’. The same event that launches medical time’s arrow serves, for Marianne, to arrest time, to paralyze her in the moment. At the same time, however, this attempt to inhabit the medical gaze indicates a possible route, through the ‘as if’ of metaphor, for the reconciliation of ‘donor’ and ‘son’. Indeed, the narrative voice of the novel attempts this through comparisons that
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explicitly inscribe Simon in a ‘mythography’ (). The dispersal of his organs is thus compared to the early modern practice of heart burial, performed on a prince ‘in order to guarantee rights to his lineage’ (). The incisions made to remove his organs evoke ‘the spear point in Christ’s side, the warrior’s sword thrust, the knight’s blade’ (). And as Rémige, in a stunning sequence, begins to sing as he prepares Simon’s body to be returned to his family, stitching together the surgical incisions and wrapping him in the shroud of a white sheet, Simon becomes an epic hero, with Rémige as a classical Greek rhapsode: it is impossible not to think of the funerary rituals that conserved the beauty of the Greek heroes who deliberately died on the field of battle; that particular treatment designed to restore their image, so that they are guaranteed a place in the memory of men. To do this, the families and the poets will sing the hero’s name, commemorate his life. It is a good death, the song of a good death. ()
In contrast to the brutal shock of Simon’s death and his conscription into the medical temporality of death, the song of the good death, with Rémige as surrogate for the novel itself and its poetic mode, generates a mythographic, literary temporality. The evocation of heroic death also recasts the twenty-four hours of the novel in different terms: no longer or not only as the rule of the medical stopwatch, but as an Aristotelian unity of time in which ‘the whole tragedy of the world’ might produce a cathartic resolution of an experience of rupture and reversal. As Jennifer Ballengee writes: ‘Tragedy posits a common memory, an imaginary community that in its presence onstage figures a means of resolution of conflicting forces.’ As Rémige’s song becomes a figure for the novel itself, the narrator along with the various characters whose attention has been focused on the organ transplant become a tragic chorus, an imaginary community, no longer riven by conflicting temporalities, but rather mutually engaged in healing the wounded, traumatic time produced in and by the age of postnatural death. What remains a question, however, is whether the mythical image of the good death invoked by The Heart can indeed survive in the age of postnatural death. The novel imagines that Rémige’s song ‘propels [Simon] into a postmortem space where death can no longer touch
Jennifer Ballengee, ‘Phantom Work: Refugees, Antigone, Comparative Literature’, in Trauma and Literature in an Age of Globalization, ed. by Jennifer Ballengee and David Kelman (New York: Routledge ), pp. – (p. ).
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Time and Narrative in the Age of Postnatural Death
him – the place of immortal glory, of mythography, the place of song and writing’ (). Literature here imagines itself as the alternative, and the cure, to medical subjectivity and its reification of the body. It transforms the violence of the automobile accident and the use of the body as biomaterial into an image of the good death, where death becomes good only as it is sublated into a vision of immortality. Literature heals the wounds of time, then, by arrogating to itself the power to transcend time, by invoking myth. But if this is the case, then literature may not simply stand as a humanizing alternative, corrective, or cure to a medicalized era. What we may perceive instead is a secret complicity between literature and medicine. The medical drive to define and master death, in this light, is but the postnatural continuation of the literary bid for ‘immortal glory’.
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Performance and/as Contagion in the Time of the COVID- Pandemic Małgorzata Sugiera
Revisiting Artaud’s ‘The Theatre and the Plague’ () in the time of the coronavirus seems to be a self-explanatory starting point of a chapter on the reciprocal relationship between performance and contagion. For almost a century, the seminal, visionary, and incendiary essay on the unbounded forces of theatrical performance, metaphorically identified with a deadly plague, has inspired many theatre practitioners and scholars. In what follows, I will shed new light on Artaud’s powerful, yet ambiguous, manifesto by situating it in the context of microbiological findings of his time as they are depicted and understood today. In order to revisit ‘The Theatre and the Plague’, however, I need to take into account not only critical modifications in medical practices and discourses on viruses, their spread, epidemics, and contagiousness made visible by the recent coronavirus pandemic. The transformations in the field of performative arts are also critical for this perspective. In recent years, traditional theatre has been increasingly losing its cultural importance to various forms of artist–activist performances that intervene in political and economic struggles and debates, situating themselves at the intersection of arts and social practices. Such performances, used as effective instruments of artist–activist intervention, reveal an intrinsic performativity of the public space. By adopting this double perspective, the chapter will comment upon the performativity of the public space with regard to, first, today’s politics of preparedness for a future epidemic in various forms of performed, hypothetical worse-case scenarios and, second, choreographies of protests that have recently been analysed by scholars employing the language of viral contagion. In other words, looking closely at significant changes in both fields – epidemiology and performance – the chapter aims to disentangle their This article was written within the framework of the project ‘Epidemics and Communities in Critical Theories, Artistic Practices and Speculative Fabulations of the Last Decades’ (UMO-//B/HS/ ), which was funded by the Polish National Science Centre (NCN).
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Performance and/as Contagion in the Time of COVID-
already naturalized interrelation in order to show their actual reciprocal relation in a new light of today’s sociocultural context. Premised on that, the chapter demonstrates that the epidemiological conceptualization of viruses, which once inspired Artaud’s analogy between his vision of a new theatre and a mighty plague, has little to do with the actual syndemic imaginary of viral diseases. In turn, this imaginary is employed here as a perspective from which to understand performativity of and performances in public space as it is the public space of virally spreading grassroots protests where the critical entanglement of performance and contagion could be effectively spotlighted nowadays.
A Look from a Speculated Future A dystopian landscape of a post-apocalyptic world in which an infectious disease of global proportion kills most of the population has become quite common in novels written and published shortly before and during the COVID- pandemic. Most of the time, their authors focus on places other than crowded playhouses and theatre institutions. By contrast, Emily St. John Mandel’s novel Station Eleven () puts theatre and its people at the very centre of the plot just before and two decades after the outbreak of a fictitious ‘Georgia Flu’. Although the novel was published a few years before the COVID- pandemic, the eponymous miniseries adaptation premiered on HBO Max in December and was widely watched by different publics in lockdown. In the series, the original Canadian setting was changed into a North American one, and the relationship between the main characters was given more prominence. Nevertheless, the novel’s rendering of the effects of how a fictional swine flu pandemic relates to theatre has remained largely unchanged. Significantly, the author presents this relation in a manner which is rather unexpected, especially in view of the decades-long naturalization of the entanglement of performance and contagion. St. John Mandel not only separates them, but also centres the novel’s narrative around a fictional graphic novel, entitled Station Eleven. In so doing, she demonstrates that ‘lowbrow’ literature (rather than theatre) has a far more important role to play in modelling human
Emily St. John Mandel, Station Eleven: A Novel (New York: Vintage Books, ). The series was nominated for seven Primetime Emmy Awards and is still listed as one of the top ten HBO TV series. On Rotten Tomatoes, it has an approval rating of per cent based on critic reviews, and an approval rating of per cent based on audience reviews [accessed December ].
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behaviour and helping people in making sense of both everyday life and traumatic experiences. Station Eleven begins on a winter night at the Elgin Theatre in Toronto, at a time when, during the fourth act of King Lear, the lead dies on stage of a heart attack. The same night, the mysterious Georgia Flu spreads quickly across the globe. Still, these two events remain strikingly unconnected. As it quickly transpires, neither was the theatre a key place in the disease transmission nor did any carrier of the contagious disease sit in the audience. Significantly, in the case of Station Eleven, the carrier turns out to be a girl who is marginal to the novel’s plot development. This authorial decision demonstrates that nowadays it is not playhouses but rather air transportation that is crucial to an epidemic spread of infectious diseases. Twenty years later, we meet a nomadic group of actors and musicians known as the Travelling Symphony. It is the end of July, and they rehearse the fourth act of King Lear walking slowly alongside their pickup trucks turned into caravans. The troupe started to perform Shakespeare’s plays and classical music five years after the collapse of the pre-pandemic civilization, and since then has been touring the Great Lakes region. While it initially staged more modern plays, audiences seemed to prefer Shakespeare. As one of the actors comments, ‘[p]eople want what was best about the world’. It seems as though it is nostalgia that motivates the fictional viewers’ choice rather than a longing for pre-pandemic high art. For them, theatre belongs to the long-lost world, together with airplanes, television guides, computers, dentists. Likewise, the Travelling Symphony’s members do not cultivate theatre as high art. Admittedly, the lead caravan has a sign saying ‘[b]ecause survival is insufficient’ written in white letters on both sides. The motto has, however, more to do with a way of living than with the specific role art played in the members’ past. In other words, the Travelling Symphony does not only operate by touring Shakespeare plays. In so doing, it also emulates Shakespeare’s theatre company and many others of his time. Because of the collapse of the pre-pandemic civilization, critically depicted in the novel’s flash-backs, the fictional theatre practitioners have a chance of returning to that particular age – to a time when theatre aesthetics and experience differed from what we have been used to since the onset of modernity. In this respect, Station Eleven echoes those recent studies on historical and contemporary pandemics that return to the times before the modern epidemiology was established; like these, it does so with an explicit aim to
St. John Mandel, p. .
St. John Mandel, pp. –.
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St. John Mandel, p. .
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critically comment on medicalized approaches to infectious diseases, their origins, ways of transmission, and efficacious strategies of their confinement. Such revisiting of the pre-modern past makes it possible to shed light on recent and increasingly visible changes in scholarly conceptualization of their reciprocity. In what follows, I start with revisiting the wellestablished, yet diversely assessed, entanglement of theatre and contagion. Against this background, I look closely at the COVID- pandemic. Like many others in the last two decades, it has been performed as a result of epidemiological preparedness which necessitates planned, implemented, evaluated, and repeated tests, exercises, and trainings in an almost theatrical simulation of a hypothetical worst-case scenario. In this context, I come back to Artaud’s text in order to reconstruct a historically distinct understanding of the pathogen on which his metaphor of performance might have been premised. Taking into account recent microbiological conceptualizations of pathogens, their mutability, and ways of spreading, I finally attempt to answer the question of whether his metaphor still holds today.
Theatre and Contagion Revisited It is still a commonly shared conviction, at least among theatre scholars and practitioners, that theatre and contagion are interconnected on many levels. Theatre belongs to those artistic and cultural practices that bring bodies together during live performances. Such performances, therefore, could easily become sites of viral transmission. Rooted in the Latin notion of touch, contagion remains semantically versatile, similarly to a number of inherited terms in the interrelated field of medicine and the arts; for instance, catharsis. In its literal meaning, contagion is something contracted via physical contact with those who have already been infected, be it through air or touched objects. That is why theatre buildings, for example London playhouses in the time of Shakespeare, were often closed down to prevent the plague’s spread. Although they remained open in the period of the Spanish flu, just after the Great War, theatres were also
See Christobal Silva, Miraculous Plagues: An Epidemiology of Early New England Narrative (Oxford: Oxford University Press, ); Anjuli Fatima Raza Kolb, Epidemic Empire: Colonialism, Contagion, and Terror, – (Chicago and London: University of Chicago Press, ); Lawrence Wright, The Plague Year: America in the Time of Covid (New York: Alfred A. Knopf, ). See, e.g., Page duBois, ‘Ancient Tragedy and the Metaphor of Katharsis’, Theatre Journal, , (), –; Joshua Billings, Genealogy of the Tragic: Greek Tragedy and German Philosophy (Princeton: Princeton University Press, ).
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among those institutions that remained closed during the lockdown in the time of the COVID- pandemic in many countries worldwide. It is difficult to determine why theatre has been considered a highly contagious cultural practice. Neither the medically modelled mechanism of disease transmission nor theatre’s capacity to represent epidemic would suggest that. Theatre has been seen as contagious when it comes to particular affects and behaviours. In his introduction to Theatres of Contagion: Transmitting Early Modern to Contemporary Performance (), Fintan Walsh addresses two widespread, albeit oppositional, ideas of theatrical contagion. On the one hand, theatre has been depicted as a socially and culturally corrupting or even destructive force by subconsciously inviting the viewer to imitate in everyday life the vices and wrongdoings represented on the stage. On the other hand, theatre has been thought of as capable of counteracting the effects of literal and figurative contagion through the invigorating exchange of information, affects, and cultural practices. Significantly, the commonly shared belief in the complex interconnection between theatre and contagion has been further reinforced by consecutive waves of the COVID- pandemic as demonstrated by a four-hour-long series of video lectures Theatre and the Coronavirus: A Speech-Act in Nine Episodes which went public in January . Rustom Bharucha, a retired professor of theatre and performance studies, recorded the lectures during lockdown in his home city of Kolkata, India. Assuming the coronavirus to be a catalyst to rethink theatre, or even to push it beyond limits of existent representational aesthetics, he looks at the impact of infectious diseases on theatre in a linear fashion, starting with the closure of Elizabethan playhouses. As one would expect, Bharucha devotes one of the nine episodes of the series entirely to Artaud, and, drawing on Judith Butler’s idea of political assemblies, also comments on the traditional Indian caste system and social distancing. In his closing remarks, the lecturer addresses the post-pandemic futures, stressing the need for a new ecologically attuned theatre architecture that could more
Not the whole world ‘froze’ in the same way; in some countries, there were no or only partial lockdowns, see, e.g., or [accessed September ]. Theatres of Contagion: Transmitting Early Modern to Contemporary Performance, ed. by Fintan Walsh (London: Methuen, ), pp. –. Rustom Bharucha, Theatre and the Coronavirus: A Speech-Act in Nine Episodes [accessed August ].
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easily adapt to a possible social distancing regime. Yet his expectations with regard to a possible impact of the pandemic on theatre artists seem to be far greater. While looking at the history of the relationship between theatre and contagion, Bharucha hints at a fundamental conflict between epistemologies of performance and epidemiology. While the latter focuses on a contagious physical contact, he argues, performance could be grasped in a more metaphysical way as capable of ‘unleashing dark forces of revelation’ as he phrases it, clearly referring to Artaud’s manifesto. Nowadays, thanks to the commonly acknowledged mutability of the coronavirus, he claims, it has become clear once again that theatre possesses the power of not only affecting but also transforming its audiences. This power could be, then, harnessed by theatre artists to strengthen their and their art’s cultural and social function. However, to see whether Bharucha’s point is a viable one, the recent changes in the conceptualization of infectious diseases and the strategies of their mitigation have to be taken into account. It is to these changes that I move in the next section.
Performing the Pandemic To better understand why the already naturalized interrelation of theatre and contagion has to be disentangled, the new conceptualization of infectious diseases and the recent performative strategies of their mitigation should be at least cursorily explored. It is especially important because a well-known model of disease co-occurrence underwent a significant transformation in the last decade of the twentieth century. In the early s, Merrill Singer – a well-known American medical anthropologist – introduced the notion of the ‘syndemic’ to call attention to the way in which large-scale social forces might synergistically interact with co-occurring epidemics. The relevance of this kind of entanglement was also clearly demonstrated by the HIV/AIDS pandemic, recognized today as the first syndemogenic disease of the contemporary Western world. It is in this sense that in its last and still the most comprehensive worldwide observational epidemiological study to date Global Burden of Disease, led by the Institute for Health Metrics and Evaluation at the University of Washington, also wrote about the COVID- pandemic in the issue
Singer coined the term ‘syndemic’ in . He provided the backgrounder for Defining Moments Canada, ‘Syndemics and Health’, Defining Moments Canada: Insulin [accessed September ].
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of The Lancet. In particular, it stressed an unexpectedly high mortality rate among patients suffering from non-communicable diseases, and connected this to the generally poor state of health of the contemporary societies. Shortly before the study was published, Richard Horton – the editor-in-chief of The Lancet – presented a broader view of the problem in his editorial ‘COVID- Is Not a Pandemic’, convinced that the present health emergency should not be framed in terms of a plague. Particularly, he focused on the tragic consequences of such a far-too-narrow approach to managing the coronavirus outbreak that mostly consisted of efforts to take control over the spread of the disease by cutting lines of viral transmission. This turned out to be insufficient because COVID- is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities. . . . Approaching COVID- as a syndemic will invite a larger vision, one encompassing education, employment, housing, food, and environment. Viewing COVID- only as a pandemic excludes such a broader but necessary prospectus.
Thus, to frame not only the recent coronavirus outbreak but also future contagious diseases in terms of syndemic will necessarily bring about significant changes in how these diseases and their interrelations with other sociocultural processes and phenomena will be conceptualized and analysed. As demonstrated by Horton’s comment, the biosocial and bioeconomic character of communicable diseases has been already recognized. To protect the health of specific communities affected by a pathogen, social and economic disparities need to be taken into account. However, health professionals focus on cultural practices and factors comparatively less often than on biological and socioeconomic interactions. Yet Merrill Singer, whose notion of syndemic has a prominent place in Horton’s comment in The Lancet, defines the term by stressing precisely ‘entwined complexes of biological, social, cultural, and often environmental factors’. This means that he connects human diseases to much larger ecosystems and various other species. In his Anthropology of Infectious Disease () – a work which sums up his former research on syndemic
‘Global Health Metrics’, The Lancet, October [accessed August ]. Richard Horton, ‘COVID- Is Not a Pandemic’, The Lancet, September [accessed August ]. Merrill Singer, Anthropology of Infectious Disease (New York and London: Routledge, ), p. .
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phenomena – Singer claims, ‘[i]nfectious diseases are at once biological realities and social constructions that reflect both biological and social relationship and interactions’. It is on this basis that he argues that the dividing line between the infection by a microbe and the disease that it apparently causes is rather arbitrary. In other words, the syndemic approach that Singer and Horton offer entails examining pathogenic agents not only in isolation, following epidemiological theory and practice, but also in their complex relationship to other non-communicable diseases and sociocultural and economic factors such as poverty and structural violence. The anthropological syndemic approach has recently allowed, for instance, observing and analysing how anticipation techniques, transferred to civil sectors after the end of the Cold War, caused a visible shift in rationalities of risk management from prevention to preparedness. In effect, regularly rehearsed simulations of future epidemics that use fictional scenarios have not only transformed the concept of contagious disease, its outbreak, common patterns, and efficient ways of confinement. They have also revealed an intrinsically performative nature of epidemic itself as something that receives its historically distinctive form through changing sociocultural practices. Vinh-Kim Nguyen, medical anthropologist and physician, demonstrates this in his comment on the March outbreak of Ebola in West Africa: ‘Ebola happened despite, and indeed as a result of, over a decade of pandemic preparedness efforts costing billions. These efforts not only failed, they produced this Ebola epidemic.’ In The Pandemic Perhaps: Dramatic Events in a Public Culture of Danger (), Carlo Caduff, quoting the above statement by Nguyen, shows how accurate this observation is. To better understand the stakes involved in the shift from prevention to preparedness, which took place around the turn of the century, I will first take a cursory look at what Priscilla Wald calls ‘outbreak narratives’ and which she believes to be pervasive in the twentieth century. In her Contagious: Cultures, Carriers, and the Outbreak Narrative (), Wald defines the outbreak narrative as an evolving story of disease emergence. The story has a formulaic plot which consists of three basic parts: ) identification of an emerging infection and its patterns, ) discussion of the
Singer, p. . Quoted in Carlo Caduff, The Pandemic Perhaps: Dramatic Events in a Public Culture of Danger (Oakland: University of California Press, ), p. . Priscilla Wald, Contagious: Cultures, Carriers, and the Outbreak Narrative (Durham: Duke University Press, ).
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global networks through which it travels, and ) an account of how the epidemiological work unfolded and ended with the confinement of the disease. As Wald insists, it is crucial to understand both the appeal and persistence of this narrative because it has the power to systematize ‘individuals, groups, populations, locales (regional and global), behaviors and lifestyles’. Thus she reads the outbreak narrative as an important biopolitical technology. In this context, narratives should be seen as aspects of social interaction as well as forms of regimented social behaviour to reinforce the governing authority. For this reason, drawing on a host of exemplary literary and cinematic works, Wald demonstrates how outbreak narratives shaped various accounts of the twentieth-century contagions, up until SARS in . Significantly, she underlines, ‘[e]pidemiologists build on precedents from previous outbreaks that they hope will make future outbreaks comprehensible, and ultimately preventable, or at least containable’. To demonstrate that the role of epidemiology was not limited to reading and writing the epidemic in such a way, it suffices to take a closer look, as Carlo Caduff does, at the critical difference between two opposed medial and generic approaches. Firstly, there are predictive approaches which predominantly result from investigation of various written epidemiological documents on important past infections. Secondly, there are mitigation measures to reduce the catastrophic effects of coming infections that try to increase the epidemic preparedness of large populations by performing simulation exercises, tests, and trainings as specific techniques, which makes it possible to immerge in the ‘reality’ of future disasters. Caduff’s The Pandemic Perhaps starts exactly at the point where Wald’s Contagious ends – in the mid-s, when, after the spread of the HN virus through Asia, seasonal influenza turned into a deadly plague and took centre stage in the US political debate, urging health professionals to prepare for the impending disaster. As policy makers believed, the disaster could not be contained but it could be mitigated if the right steps were taken. Thus, preparedness became increasingly a generic remedy, triggering a kind of inherently performative, even prophetic discourse. Significantly, the public was not addressed as a passive audience for staged exercises in the discourse. It was addressed as an active participant, engaged in all kinds of simulation exercises. Step by step, Caduff does not only demonstrate how influenza became a subject of scientific divination. He also explains why ‘pandemics of the present are increasingly perceived as tests for pandemics of the future’. Although The Pandemic Perhaps was
Wald, p. .
Wald, p. .
Caduff, p. .
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Performance and/as Contagion in the Time of COVID-
published in , the COVID- pandemic has corroborated Caduff’s thesis – in today’s politics of preparedness, this actual pandemic has often been treated exactly as a ‘real’ test for the next disaster – already in the making – because of, for instance, climate change and global warming. This is also the reason why, bombarded as we are almost every week with news about new mutations and their respective serial names, we have serious difficulties believing in the ‘realness’ of the pandemic, despite such large numbers of the infected and dead. The pandemic has appeared as a kind of ‘unreal’ theatre performance that takes place outside theatre buildings and influences our everyday lives. It is precisely in this context that I would like to come back to Bharucha’s recent reading of Artaud’s ‘The Theatre and the Plague’.
The Viral Artaud Speaking about ‘The Theatre and the Plague’ in his lecture series, Bharucha refers to a widely read Stanton B. Garner’s article ‘Artaud, Germ Theory, and the Theatre of Contagion’ (), in order to place Artaud’s manifesto in the context of the microbial knowledge of the prewar period. Indeed, Garner begins his argument by pointing at unexpected ways in which Antonin Artaud and Louis Pasteur, a key figure of modern epidemiology, were linked, although they were not one another’s contemporaries. He does so in order to offer a genealogical perspective on the history of constant conceptual intertwining of theatre and contagion in the twentieth century. On the one hand, Garner states that Artaud has been a pivotal figure in this recurring identification of theatre and contagion because ‘theatre and infectious disease become defining metaphors for each other’ in ‘The Theatre and the Plague’. On the other hand, however, he stresses that the manifesto ‘resists the medicalized language it depends on’, and thus demonstrates ‘Artaud’s profoundly ambivalent attitude toward the body as organic entity and toward medicine as science of the flesh’. Therefore, Garner argues, ‘[e]ven those playwrights, like Artaud, who rejected the scientism of the germ theory employed a poetics of contagion in dialogue with the microbiological model of disease transmission’. I quote Garner extensively to demonstrate that while writing about the microbiological model of the pre-war time, he depicts
Stanton B. Garner, ‘Artaud, Germ Theory, and the Theatre of Contagion’, Theatre Journal, , (), –. Garner, p. . Garner, p. . Garner, p. .
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Artaudian plague as a viral contagion. This means that he does not take into account a significant difference between contagious agents of such communicative bacterial diseases as typhoid fever and diphtheria, even though the difference between the two was well known in the early twentieth century. Contrary to epidemiological findings of his time, according to which the bubonic plague was supposed to be caused by the bacterium Yersina pestis, Artaud consistently refers to the causative agent as ‘the most pernicious of viruses’. It is not, as I believe, by accident that ‘The Theatre and the Plague’ does not speak about germs, microbes, or – more particularly – bacteria. Although consciously referring to historical outbreaks of the plague, Artaud chose the virus as a more powerful metaphor of dark forces which theatre is capable of unleashing on purpose. To understand this gesture, one has to take a look at the microbiological scene of the early twentieth century. In The Pandemic Perhaps, Caduff writes, ‘[i]n the early twentieth century the concept of the virus referred to an obscure object defined primarily in negative terms’. The reason for that, he further explains, was quite evident: even the most powerful microscopes of that time did not make it possible to see the virus which penetrated freely through physical barriers of the finest filters. Moreover, microbiologists were unable to cultivate it in the lifeless media they used in their laboratories. In other words, even after the first successful isolation of the influenza virus from a human host ( in London), researchers did not see the virus; they managed to make it visible only as a trace. As Caduff explicitly comments, ‘[a] distinctive set of knowledge practices made the invisible agent concrete: The virus became detectable, maintainable, manipulable, and transferable. However, what researchers revealed was not the virus itself, but the trace that it left after it had entered susceptible bodies.’ Due to the peculiar nature of these entities, microbiologists ascribed to them such properties as agency, mobility, and intentionality even after the Second World War. This has been captured in the famous saying of the renowned French microbiologist and Nobel Prize winner André Lwoff in his lecture, ‘[v]iruses should be considered as viruses because viruses are viruses’. The ontological singularity of viruses must have strongly affected Artaud’s poetic imagination, which is clearly visible in two pivotal images
Antonin Artaud, ‘The Theatre and the Plague’, in Artaud, The Theatre and Its Double, trans. by Mary Caroline Richards (New York: Grove Press, ), pp. – (p. ). Caduff, p. . Caduff, p. . André Lwoff, ‘The Concept of Virus: The Third Marjory Stephenson Memorial Lecture’, Journal of General Microbiology, , (), – (p. ).
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Performance and/as Contagion in the Time of COVID-
of ‘The Theatre and the Plague’. The text opens with a viceroy of Sardinia’s premonitory dream about a scourge ravaging his state after it has passed all physical barriers on its way unnoticed. After the first image in Artaud’s manifesto comes the second – the image of the diseased body which manifests and materializes the invisible contagion in the pathogenic state of internal organs, now visible to all. Thus, like in microbiological laboratories of his time, Artaudian visionary plague, supposedly transmitted by a virus, makes itself visible only as a trace and a symptom in both real life and theatre. Therefore, the plague could be recognized as the very essence of the theatre because the actor’s body, which materializes meanings and affects, serves as a genuine source of communication with audiences. It is to this bodily materialization of what remains unseen and unseeable that Artaud refers while speaking about what happens to and with the actor’s body on the theatre stage as a ‘spiritual image of the plague’. Theatre and communicable disease share one characteristic feature: something invisible, and, for that reason, unreal, gains reality thanks to a set of distinctive materializing practices. Moreover, theatre, just like a laboratory, remains strictly separated from the external world, and this considerably helps maintain (apparent) control over fictional and real contagion. In view of this, I would question Garner’s stance as to Artaud’s ambivalent attitude towards the scientific knowledge of his time, ‘the scientism of the germ theory’. Rather, I would argue that in his ‘Theatre and the Plague’, Artaud congenially detects the very point where the microbiology of his time reaches its limit, forced to define the object of its study solely through knowing what the object is not and cannot do. In my reading, the definition by negation powers the Artaudian vision of ‘this superior version of the theatre’ and remains a crucial factor in fulfilling theatre’s vital cathartic function. Mindful of the correspondences between how the virus functions in ‘The Theatre and the Plague’ and how it was conceptualized in the early twentieth century, in what follows I look for a counterpart of this correspondence nowadays when strategies of preparedness and exercises of a worst-case scenario in public space have superseded the idea of controlling contagious diseases in laboratories. As already signalled by my reading of Station Eleven, this will necessitate going out of playhouses to engage with ways of how unruly bodies organize themselves in public spaces to disrupt the smooth and seemingly efficient functioning of social and political life.
Artaud, pp. –.
Artaud, p. .
Garner, p. .
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Artaud, p. .
Contagious Spirit of Resistance In her Viral Performance: Contagious Theatres from Modernism to the Digital Age (), Miriam Felton-Dansky sketches a historical lineage from Artaud to today’s viral culture. For her, the best example of this culture is Caryl Churchill’s Royal Court production of Seven Jewish Children, which she calls ‘a new species of performance, self-consciously created for rapid international circulation: viral performance for the twenty-first century’. Interested primarily in how viral dramaturgies of this kind draw on emerging media to develop new modes of rapid and multidirectional dissemination of ideas, gestures, and images, FeltonDansky considers viruses of all sorts to be natural allies for consecutive generations of avant-garde artists such as the radically political ones of the s and early s. She subsumes this sort of practice under the umbrella term of ‘Germ Theater’. The collective Critical Art Ensemble, the duo Eva and Franco Mattes, and the German theatre director Christoph Schlingensief are of particular interest in the context of this chapter. They clearly rebelled against the then-valid ideals of theatre performance, and used media-fuelled provocations that were received and experienced as ‘real’ by large audiences. Blurring the boundaries between fictive theatrical action and real-world intervention, artists of the Germ Theater aimed to spread distrust about neoliberal politics, globalized economies, and controlling government agencies. Critical Art Ensemble’s Marching Plague (), in which the physical components of the germ warfare were used, is a case in point. Despite revealing the performed realities as fictional at the end, Germ Theater’s practitioners still pushed the spectators towards a particular mode of participation, controlling the spread of ideas and affects in this way. Unlike these artist-activist interventions, choreographies of protest, which have become increasingly widespread in the s and on which I focus, count on more unpredictable modes of participation. To demonstrate the difference, I offer a closer look at two specific examples from Poland – one mentioned in the Felton-Dansky book, another, more recent, situated in our pandemic time. In her book, Felton-Dansky depicts historically distinct forms of deep engagement with the terms of theatre dissemination, which forced many
Miriam Felton-Dansky, Viral Performance: Contagious Theatres from Modernism to the Digital Age (Evanston: Northwestern University Press, ), p. . Felton-Dansky, pp. –.
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artists to go out of the theatre building into public space, particularly at the turn of the last century. However, to conclude, she focuses on a performance which pointed ‘toward a mode of viral performance that does indeed depart from the media-fuelled panics and the bio-art incitements of twentieth and early twenty-first-century viral performances’. Born in this context, Polish artist and curator Joanna Warsza’s performance Virus in the Theater on the stage of Warsaw’s TR Warszawa was performed only once. However, as Felton-Dansky writes, it ‘reenvisioned the virus as a model for the deliberate opening of perceptual space’ because it was staged as an intervention of a Polish performance duo Sędzia Główny in a performance of the Polish nineteenth-century romantic comedy of manners, Aleksander Fredro’s Śluby Panieńskie (Maiden’s Vows), a repertory standard. Once on stage, the intervening duo asks the spectators what they would like the performers to do. Having executed some more or less explicit commands, the duo leaves the stage, and the performance of Fredro’s comedy continues as if nothing happened. I am not sure whether I have rightly recognized the reason why this homage to the Italian Futurists, as the creator herself explained, has attracted FeltonDansky’s attention, but she singles it out because it offers ‘one way that viral performance will endure: as a break, a rupture, a point of difference in a sea of sameness, one that does not necessarily spread through replication, one that may not need to spread at all’. However, the author offers this utopian vision of a unique virus ‘that did not aim to go viral’ in the book published in the decade when various grassroots protests clearly demonstrated that digital dissemination is still far from being the only way to spread viral contagion in performance arts. To show this I will take a closer look at a theatre performance staged during a public protest in Warszawa almost fifteen years later. On Halloween night of , the second part of the Polish romantic play Dziady (Forefathers’ Eve), slightly adapted for this occasion, was staged in large, spotlighted windows of a Warsaw tenement house at / Mickiewicz Street, named after the author of the play. One of the central factors behind this collective tenements’ action was the fact that the private domicile of Jarosław Kaczyński, leader of the Polish governing right-wing party Prawo i Sprawiedliwość, was situated across from the building.
Felton-Dansky, p. . Felton-Dansky, p. . Felton-Dansky, p. . Felton-Dansky, p. . For more details see Łucja Iwanczewska, ‘A kysz! Albo: proszę uciekać szybciutko’, Didaskalia, () [accessed August ].
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For everybody present that night it was also clear that Kaczyński was one of the otherworldly presences haunting people gathered at this pre-Christian Slavic ritual, which in the play not only commemorates the ancestors but also serves to exorcise the most dangerous revenants. A political staging of a canonical play is nothing new, and Mickiewicz’s play – albeit not this part – was often used as a commentary to historically distinct sociopolitical situations of its audiences. However, during the October performance, the second part of Dziady was performed only once, and, more importantly, as a part of mass protests against further restrictions on abortion in Poland, which made it practically illegal. The gathering was also formally illegal because of the official lockdown. Thus, everybody present was aware of the fact that they could be prosecuted and penalized. Significantly, although only some of the protesters were there because of the performance, as the play belongs to the Polish theatre canon, it is highly improbable that anybody present could mistake it for ‘reality’. In this respect, what happened on the Halloween night differs clearly from publicly performed, large-scale stagings of Germ Theater’s artists. By no means could this performance be identified as the only source of affects and reactions that night. Its theatricality was not particularly striking because many people in the crowd were dancing, jumping, and playing around in self-made costumes, presenting self-made props and slogans as in many recent political demonstrations in Poland and beyond. However, in retrospect, the performance of Dziady helps to see how today’s perception and understanding of the performativity of public space has changed, among others under the influence of the new conceptualizations of viruses as ever-shifting, ever-changing relationalities of bodies and their environment. In her article ‘Choreographies of Protest’, Susan Leigh Foster takes a closer look at three different examples of non-violent direct protestactions in the recent US history: the lunch counter sit-ins of , the ACT UP die-ins of the late s, and the World Trade Organization meetings protest in Seattle, Washington in . Her analysis demonstrates that despite all their differences, these protests share not only a grassroots profile but also a lack of any charismatic leader. Not intending to read these events as dances, she nevertheless calls them choreographies of
It differs also from performances I analysed in my former article on theatre and contagion entanglement – see Małgorzata Sugiera, ‘Theatre as Contagion: Making Sense of Communication in Performative Arts’, Text Matters: Journal of Literature, Theory and Culture, (), –.
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Performance and/as Contagion in the Time of COVID-
protest to show the range of kinaesthetic responses, the way that ‘bodies make articulate choices based upon their intelligent reading of other bodies’, and the ‘endeavor to frame a new perspective on individual agency and collective action, one that casts the body in a central role as enabling human beings to work together to create social betterment’. Two decades later, although they still use Foster’s term to characterize all kinds of dance-ins, zaps, lock-ons, flash mobs, and smart mobs, dance scholars tend to employ the language of viral contagion, writing about individual, present and historical bodies which infect one another (or were infected) with rhythm and movement, free to adapt or mutate them depending on the specific energy of their own body. A case in point is Kélina Gotman’s Choreomania (), which deals with nineteenthcentury phantasies of medieval and colonial outbreaks of dancing and singing as a threat to social order. Uncovering a rather unknown history of such ‘dancing disease’, which creates disorder, Gotman points out that, like in the past, today, the unruly moving bodies exercise ‘a wider range of motions and displacements than is normally, normatively allowed’. Therefore, ‘the way bodies move in and have the capacity to move public space’ has the potential to reorganize extant hierarchies and orders. In this respect, choreographies of protests which spread ideas and affects seem to be on the other pole of spectrum of performances of preparedness, which Caduff analyses that primarily aim to control the future.
Instead of Closing Comments It seems impossible to close this chapter’s argument in the culture of preparedness in which almost every influenza outbreak becomes a test for the next, ‘real’, pandemic and in which mass non-violent protests express anger and defiance vis-à-vis extant political regimes and leaders. The explicit intention of this chapter has been far more modest from the outset – to demonstrate that it is not enough to state that whenever people gather, something spreads. In order to spotlight a historically distinct form of the reciprocal relationship between cultural practices and contagion, it is necessary to focus on what spreads and how it does so. Mindful of that, I attempted to disentangle the naturalized interrelation of theatre and contagion by offering a reading of Station Eleven which shows that not
Susan Leigh Foster, ‘Choreographies of Protest’, Theatre Journal, , (), – (p. ). Kélina Gotman, Choreomania: Dance and Disorder (Oxford: Oxford University Press, ), p. . Foster, p. xiv (original italics).
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every place where people gather must spread contagion. Otherwise, it would hardly be possible to tell apart the epidemiological conceptualization of viruses as obscure forces identifiable only as traces in bodies (which inspired Artaud’s misreading of the historical plague) from today’s syndemic imaginary of viral diseases as a perspective from which to perceive and understand performativity of public space. Indeed, it is not so much theatre but public space where the critical entanglement of performance and contagion could be spotlighted nowadays.
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The Parallel Chart as Medico-Literary Practice Daniel Eison
The writing of a parallel chart is a medico-literary practice invented by internist Dr Rita Charon as part of narrative medicine. Despite its recognition as a revolutionary methodology and widespread inclusion in the repertoire of narrative medical techniques, there has been little consideration of the form’s development in the context of its historical antecedents and the progeny it has since spawned. This type of analysis is necessary to properly understand the parallel chart as a form that is both innovative in the domain of medical humanities practice and has worked to subvert the traditional balances of power in the clinical medical setting. This chapter thus begins by exploring the design and structure of the parallel chart, and then briefly looks at the trends in the history of teaching medical humanities that informed its invention. Subsequently, the chapter explores how the parallel chart functions as a pedagogical tool in present-day medical education and mobilizes narrative medicine theory into practice, presenting examples of its deployment in multiple different educational and clinical arenas. Finally, it also addresses some of the practical and theoretical critiques of the parallel chart practice. Although narrative medicine is intrinsically a transdisciplinary and international field of study that has applications to all branches of healthcare, this article examines the English-language literature on the subject, which primarily focuses on physicians and on the US medical educational environment. The chapter also explores the significant body of parallel chart scholarship written in English that has been blossoming in Italy in the last two decades under the influence of the Italian Society of Narrative Medicine and the narrative medicine program at Milan’s Istituto Studi Direzionali. There are almost certainly examples of – and innovations in – the parallel chart form recorded in the non-English academic literature that
Rita Charon, The Principles and Practice of Narrative Medicine (Oxford: Oxford University Press, ), p. .
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are beyond the bounds of this chapter. There are likewise applications of the form in fields such as dentistry and social work that are also outside the chapter’s scope, yet still represent important frontiers in the work of narrative medicine.
Charon’s Pioneering Work Since Charon first conceived of the parallel chart, the form has been adapted to numerous settings with many types of participants. Many of the chart’s features have remained consistent across its various iterations. The eighth chapter of Charon’s book, Narrative Medicine: Honoring The Stories of Illness, provides a source for the structure of the parallel chart as she first developed and implemented it as an exercise for student physicians in an MD degree programme in the United States. The present chapter takes that version as the common ancestor from which other forms have evolved. Its features will serve as a baseline against which other versions may be contrasted. Fundamentally, the parallel chart is a hybrid exercise, including written and verbal, solitary and social, and personal and professional elements. It is a formal practice that first creates and then collaboratively analyses a written text. In its first iteration, Dr Charon asked small groups of medical students at Columbia University Vagelos College of Physicians and Surgeons to ‘write about their patients in ordinary language’, generating texts that would then be shared in a precepted discussion. Even those who were sceptical of writing were asked to put words down on paper because the ‘textual act’ is the primary site of engagement. Charon’s goal in having her students write was to ‘deepen writers’ abilities to capture perceptions and to represent them fully’. In responding to their pieces, she would guide the discussion to focus on elements of textuality rather than the content of the narrative: ‘genre, temporality, metaphors, narrative situation, [and] structure . . . frame, form, time, plot, and desire’. The construction of the text, rather than the story it tells, was the primary
Jean-Noel Vergnes, Nareg Apelian, and Christophe Bedos, ‘What about Narrative Dentistry?’, Journal of the American Dental Association, , (), –; Janet L. Woldt and Monica W. Nenad, ‘Reflective Writing in Dental Education to Improve Critical Thinking and Learning: A Systematic Review’, Journal of Dental Education, , (), –. Narrative in Social Work Practice: the Power and Possibility of Story, ed. by Ann Burack-Weiss and others (New York: Columbia University Press, ). Rita Charon, Narrative Medicine: Honoring the Stories of Illness (Oxford: Oxford University Press, ), pp. –. Charon, Honoring, p. . Charon, Honoring, p. . Charon, Honoring, p. .
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The Parallel Chart as Medico-Literary Practice
subject of discussion and analysis. Subsequent implementations of the parallel chart have not always stayed true to this focus on form over content, as some of the studies discussed later in this article demonstrate. The collaborative nature of the exercise made certain demands on textual form. Charon asked her students to write no more than one page each time to allow for each piece to be read aloud and discussed. The sharing also shaped the content of the pieces. Charon warned students at the outset that they would recite to the group, signalling ‘the proper level of disclosure for this exercise’, and precluding content that was ‘unduly private’. This caution was merited because the narratives could be deeply personal. Charon explicitly encouraged writers to engage with their own emotions: If your patient dying of prostate cancer reminds you of your grandfather, who died of that disease last summer, and each time you go into the patient’s room, you weep for your grandfather, you cannot write that in the hospital chart. We will not let you. And yet it has to be written somewhere. You write it in the Parallel Chart.
She urged her students to explore the attachment, awe, helplessness, rage, shame, and humiliation they felt in their clinical work, baring those parts of their experience that have few or no legitimate outlets within the professional structures of medical practice. ‘Among the most lasting lessons of my Parallel Chart work’, writes Charon, ‘is how central and exposed is the doctor’s self in the care of patients’. Not only did the texts excavate the emotional spaces of practice, but the sessions of sharing could leave all present ‘stunned’ and ‘in tears’, requiring the preceptor to carefully guide her pupils out of that raw and fragile state and back into the professional realm to resume their duties. Charon reports that her students saw the experience more beneficial than taxing, though, relating that they found comfort in knowing they were not ‘alone in their mournfulness or sadness or guilt’. She is emphatic, however, that the parallel chart was not intended to be a therapeutic intervention. Any emotional well-being the students derived was secondary to the goal of training better physicians. By teaching students to ‘recognize more fully what their patients endure and to examine explicitly their own journeys through medicine’, parallel charting was designed to increase
Charon, Honoring, p. . Charon, Honoring, p. . Charon, Honoring, p. . Charon, Honoring, p. (emphasis in original). Charon, Honoring, p. . Charon, Honoring, pp. –. Charon, Honoring, p. . Charon, Honoring, p. .
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the students’ capacity for clinical work. Charon makes the case that the parallel chart exercise ‘improves students’ skills in seeing from their patients’ points of view, a capacity requiring cognitive and imaginative flexibility . . . one critical and currently missing skill in health care professionals – and one that can be taught’. Piloted with medical students who were encountering patient care for the first time, subsequent applications were performed with physicians at other levels of training and in fully fledged practice. Not all implementations of the parallel chart have stayed true to Charon’s original focus on form over content, though, as some of the studies discussed later in this chapter demonstrate. Nor do all evolved versions of the exercise include reading aloud or peer sharing, but the creation of a written text remains a central feature of the parallel charting practice. Nearly all cases preserve the focus on strengthening clinicians’ capacity to provide patient-centered, conscientious medical care.
Historical Context The parallel chart, and narrative medicine more broadly, are heirs to a long tradition of mobilizing the liberal arts to augment the skill of physicians and turning literary writing to the service of patient care. In the late nineteenth and early twentieth centuries, the teachings of renowned physician William Osler shaped the fundamentals of modern medical education. Osler saw the humanities as a remedy for the demoralizing circumstances of medical practice that could inspire cynicism in trainees. Reading literature and philosophy, though, would fortify the character of physicians, by helping them to master the traditional ideals of European culture. Still, medicine was the vocation and literature the avocation, an ‘intellectual pastime’ and ‘outside hobby’, which would provide a restorative reprieve from the scientific work of medicine: ‘When tired of anatomy refresh your minds with Oliver Wendell Holmes; after a worrying subject
Charon, Honoring, p. . John P. Geyman, ‘The Oslerian Tradition and Changing Medical Education: A Reappraisal’, Western Journal of Medicine, , (), –; Helen Leach and Jamie J. Coleman, ‘Osler Centenary Papers: William Osler in Medical Education’, Postgraduate Medical Journal, , (), –. William Osler, ‘An Address ON THE MASTER-WORD IN MEDICINE: Delivered to Medical Students on the Occasion of the Opening of the New Laboratories of the Medical Faculty of the University of Toronto, October st, ’, British Medical Journal, , (), – (p. ). Osler, p. . Aaron Manson, ‘The Fate of Idealism in Modern Medicine’, Journal of Medical Humanities, , (), –.
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The Parallel Chart as Medico-Literary Practice
in physiology, turn to the great idealists, to Shelley or to Keats, for consolation; when chemistry distresses your soul, seek peace in the great pacifier, Shakespeare; ten minutes with Montaigne will lighten the burden.’ He counselled students to compile a bedside library and spend ‘the last half-hour of the day in communion with the saints of humanity’. Thus the humanities, while lauded, were sequestered to private time and given the status of a tonic to ease the doctor’s professional dyspepsia. Later advocates of humanism in medicine also saw the conditions of contemporary practice as a threat to the humanistic qualities of physicians, which compromised their ability to provide compassionate care. The foundation of the Society for Health and Human Values (SHHV) in , which heralded the development of modern medical humanities and bioethics, was a response to the ‘[d]epersonalization and biological reductionism’ that had arisen as unintended side-effects of the Flexnerian revolution in medical training. Abraham Flexner’s report entirely reshaped medical training in the United States, emphasizing the importance of scientific rigour and inspiring the canon of biological, chemical, and physical sciences that still comprise the premedical university curriculum and marginalize the liberal arts and humanities. Eric J. Cassell, writing on ‘The Place of Humanities in Medicine’ in , charts a consequent nadir in the humanities’ influence on medical education and oscillating enthusiasm for the liberal arts through the following decades. As such, the founders of the SHHV sought to reintroduce and emphasize human values in medical education in order to train more competent, caring, and effective physicians. Into the twenty-first century, the humanities never yet seemed to lose their second-class status or their role as a nostrum for professional dissatisfaction. Teachers of medical humanities still fight for space in the interstices between biochemistry and pathophysiology, the history of medicine is relegated to singular and simplistic lectures, and in many
William Osler, ‘After Twenty-Five Years: An Address at the Opening of the Session of the Medical Faculty, McGill University, Sep ’, Montreal Medical Journal, (), – (pp. –). Osler, ‘After Twenty-Five Years’, p. . Daniel M. Fox, ‘Who We Are: The Political Origins of the Medical Humanities’, Theoretical Medicine, , (), – (p. ). Eric J. Cassell, The Place of the Humanities in Medicine (New York: The Hastings Center, ), p. . Johanna Shapiro and others, ‘Medical Humanities and Their Discontents: Definitions, Critiques, and Implications’, Academic Medicine, , (), –.
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schools, humanities courses are strictly elective. One current tactic to advocate for the inclusion of the humanities has been to present them as part of the wellness efforts that academic institutions and healthcare corporations have been implementing to retain alienated and burnt-out clinicians, leading to a proliferation of research demonstrating narrative medicine’s beneficial effects on resiliency, professional identity, and burnout avoidance. This narrative-as-wellness approach contradicts Charon’s original intention that it should not be primarily a form of therapy, yet it continues to flourish in the current climate of corporatized healthcare. The parallel chart and narrative medicine focus less on the character of the physicians or the values they hold and centre instead on the relationality between physician and patient that arises from literary representation. Charon describes assigning her medical students to write the events that brought their patients to the hospital as fictional narratives in the patients’ imagined first-person point of view. This aspect of the parallel chart is the successor to a different medical tradition that was concurrent with Osler’s: Sigmund Freud’s case histories. Freud pioneered the use of literary techniques in the case history genre to lay open his novel methods of psychoanalysis. The primary device that he used was point of view, transcribing his patients’ narratives in their own words to provide his readers with a sense of verisimilitude and to show how his analysis functioned to elucidate the hidden meanings of those words. Freud drew on the literary techniques of the realist novelists whose fiction was deeply concerned with the inner lives of their characters. Among these contemporary authors was Henry James, famously an explorer of his characters’ interiority and also the subject of Rita Charon’s PhD dissertation. Charon draws on James frequently in her writings, notably lauding his depiction of the ‘relational process’ between physician and patient in The
Lisa R. Dittrich, ‘Special Theme: Humanities Education-Preface’, Academic Medicine, , (), –. Christy DiFrances Remein and others, ‘Content and Outcomes of Narrative Medicine Programmes: A Systematic Review of the Literature through ’, BMJ Open, , (), e. Rita Charon, ‘To Render the Lives of Patients’, Literature and Medicine, , (), – (pp. –). Carol Berkenkotter, Patient Tales: Case Histories and the Uses of Narrative in Psychiatry (Columbia: University of South Carolina Press, ), pp. –. Berkenkotter, p. . Berkenkotter, p. . Rita Charon, ‘“The Great Beheld Sum of Things”: Intersubjective Studies of Henry James’ Literary Studies of Medicine’ (unpublished doctoral thesis, Columbia University, ).
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The Parallel Chart as Medico-Literary Practice
Wings of the Dove. That relationality is built, Charon argues, by the literary act of parallel charting. Rendering a patient’s life in a narrative form draws that life closer to the life of the writer, connecting the writer to ‘the presence in [the patient’s] life of feeling, of a home, of meaning’, providing a means to confront negative emotions ‘from a safe distance’. This blend of intimacy and safety comes from the ‘simultaneous identification and distance’ that a writer can experience in writing, the ‘oscillation between empathy and objectivity’ that writing allows more easily than doctoring: ‘The writer can use the objectivity as food for the empathy and vice versa, and can experience them not as conflicting but as dual aspects of the same task.’ The cognitive and emotional work thus performed through parallel charting is not peripheral to the work of clinical medicine. Whereas the Oslerian heritage and narrative-as-wellness sideline the humanities to a supporting role, Charon’s practice centralizes narrative work, positioning it as fundamental to the practice of medicine, coequal with scientific acumen and knowledge of biomedicine. As such, narrative competency must be taught to trainees. The skills imparted to the student of narrative mirror, and thus augment, some of the capacities already taught by clinical medical training, like gathering information, thinking critically, and making decisions: To understand a patient’s history, to reach diagnostic conclusions, to engage in a therapeutic alliance, to come to individual decisions about the contours of care, to make policy decisions about medical resources – these are but a few of the activities of the doctor that rely not solely on the biomedical sciences but also on the knowledge and methods of the humanities.
Narrative medicine also purports to teach skills that are not proffered by traditional medical training but are just as important to clinical practice. Charon draws a parallel between the ability to ‘follow a logical thread, justify a decision, interpret equivocal data, seek evidence, and draw apt analogies’, and the capacity to ‘follow a narrative thread, recognize meaning in seemingly random events, tolerate ambiguity, adopt others’ perspectives, frame events within social and historical perspectives, and reconcile
Rita Charon, ‘Narrative Medicine: Attention, Representation, Affiliation’, Narrative, , (), – (p. ). Charon, ‘To Render’, p. . Charon, ‘To Render’, p. . Rita Charon and J. D. Peter Williams, ‘Introduction: The Humanities and Medical Education’, Academic Medicine, , (), – (p. ). Charon and Williams, p. .
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competing values’. The skills of literary analysis apply to the critical reading of the parallel chart and, crucially, to the daily clinical practice of the clinician. So the student of narrative medicine reads The Wings of the Dove not only to absorb its masterful portrayal of relationality but to practise the very skills that will allow that student to create relationality in the clinic. Proponents of narrative medicine argue that these are crucial skills for all clinicians to master, and that rigorous narrative training can be their source.
Pedagogy The parallel chart exercise seeks to train clinicians in narrative skills within the framework of their clinical practice, embedding the lessons of the literature seminar in the doctor’s office. Among the parallel chart’s most salient lessons is the capacity for attention. The exercise begins when each student listens to their patient’s story. Then, when asking students to share their writings in the small group, Charon does not have them distribute copies of their written text; they only read it aloud, compelling the others in the group to ‘listen very intently’. Starting with attention reflects one of the major schemata of narrative medicine that Charon outlined in her seminal paper entitled ‘Narrative Medicine: Attention, Representation, Affiliation’. She outlines three movements that occur when narratives are related in healthcare settings. The process starts with attention: not mere listening, but rather the type of attention that requires the listener ‘to become a receptive vessel for the language and experience of another’, and is an ‘imaginative, active, receptive, aesthetic experience of donating the self toward the meaning-making of the other . . . a dramatic, daring, transformative move’. The attention that participants rehearse in their parallel chart sharing sessions is the same they perform in listening to the patients whose stories inform those charts. Each part of the exercise reinforces the other and conditions the participants to bring their full attentive capacity to all of their patient encounters. The second and third movements, representation and affiliation, follow from attention. After listening, the parallel charting student begins to write. In representing, ‘the imagination metabolizes its associated memories and sensations and perceptions’, allowing the listener-turned-writer to discover novel aspects of the received narrative, giving form to the formless
Charon and Williams, p. . Charon, ‘Attention’, p. .
Charon, Honoring, p. . Charon, ‘Attention’, p. .
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The Parallel Chart as Medico-Literary Practice
experience of attending. The created text allows the writer, and then colleagues, to ‘behold’ the experience of their patient interaction from new angles that were inaccessible before it was rendered as text. This is why, as I have discussed, Charon insists that all participants write, and then read aloud exactly what they have written. In practising writing and listening, the students augment their skills of attention, leading to better representation of the patients’ stories in the students’ writing. Attention and representation, in a positive feedback loop, then synthesize affiliation. Affiliation is a connection and alliance with patients, with colleagues, and with the institution of medicine itself. Strengthening these bonds ‘can enable us to know in earthy, rich detail that we are affiliated as humans, all of us humble in the face of time, ready to suffer our portion, and brave enough to help one another on our shared journeys’, thus leading to a more just and compassionate form of medical care. The parallel chart uses representation to create affiliation in a way that is unique among narrative methodologies because it is a chart. It is a document intentionally paralleling, and thus in conversation with, the medical chart itself. The structure of the clinical note contributes to clinicians’ alienation from their patients’ stories. The classic form of the medical note separates ‘subjective’ from ‘objective’ sections, placing patient narratives firmly in the former and reserving the latter for evidence from the physical examination, laboratory tests, and imaging studies. The physician’s own interpretations and recommendations, correlating and analysing both subjective and objective data, reside in the ‘assessment’ and ‘plan’ sections that follow. The parallel chart enforces no such distinctions. The parallel chart is also written in language that is non-medical. Nowaczyk, writing on parallel charting in a clinical genetics practice, describes medical jargon as both a ‘crutch’ and a ‘shield’. Cast aside by clinicians who are writing narratively, jargon no longer blocks their connection with explicit and implicit meaning of their patients’ words. Paolo Banfi and colleagues’ qualitative study of the parallel charts written by Italian pulmonologists treating chronic obstructive pulmonary disease found that physicians who used more technical disease-related terminology
Charon, ‘Attention’, pp. –. Charon, ‘Attention’, p. . Małgorzata J. M. Nowaczyk, ‘Narrative Medicine in Clinical Genetics Practice’, American Journal of Medical Genetics Part A, , (), – (p. ).
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also reported the most difficult relationships with their patients. Hobbs’s discourse analysis of resident physicians’ clinical notes shows numerous ways physicians use stylistic techniques as markers of evidentiality, showing the provenance and thus trustworthiness of information. One such tactic is the ‘attribution shield’, where the doctor writes, ‘patient complains of’, ‘states’, or ‘denies’, signifying to the reader that such information should be independently weighed and evaluated because it is hearsay. By contrast, reports of the findings or actions of other medical personnel are most often written in the passive voice or as agentless constructions, like, ‘patient was found to be bleeding’. Findings from the exam and bloodwork are often presented with no qualifiers at all, implying their complete factuality. Though no comparable discourse analysis of parallel charts has been done, the examples of writing given in any number of sources (Charon’s included) demonstrate few of the stylistic markers Hobbs noted and are written in a literary style. Markers of evidentiality are superfluous because the parallel chart makes no distinction between subjective and objective. There is no dividing line between the patient’s story and the clinician’s findings and interpretation (or the clinician’s story, one might properly say). The document is a singular whole, and an exercise in imaginative creativity, unconcerned with delineating fact from fiction. Wood discusses the narrative medical write-up as a new literary form that ‘explicitly transcends literary categories. It is neither fact nor fiction, neither biography nor autobiography, but, rather, an amalgam that tells as much about the student as the patient and is as true as it is imagined.’ He goes on to explain that the plot of the parallel chart entry functions similarly to the format of the traditional medical ‘history and physical’ note, because in both, ‘the act of narration imbues the events with coherence and significance’. Whereas the clinical note leads to a diagnosis and plan for treatment, the narrative write-up’s conclusion is ‘a sense of experience or meaning’.
Paolo Banfi and others, ‘Narrative Medicine to Improve the Management and Quality of Life of Patients with COPD: The First Experience Applying Parallel Chart in Italy’, International Journal of Chronic Obstructive Pulmonary Disease, (), – (p. ). Pamela Hobbs, ‘The Use of Evidentiality in Physicians’ Progress Notes’, Discourse Studies, , (), – (p. ). Hobbs, pp. –. James Hunter Wood, ‘Interventional Narratology: Form and Function of the Narrative Medical Write-Up’, Literature and Medicine, , (), – (p. ). Wood, p. . Wood, p. .
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The Parallel Chart as Medico-Literary Practice
Charon mobilized the inventive, quasi-fictional nature of these narratives to connect her pupils more deeply with their patients. She remembers a medical student who did not know a detail of his patient’s history, flummoxed by her instruction to ‘make it up’, as a way to investigate why his care felt inadequate. Pure invention obviously has no place in the official medical chart, but in the parallel chart it deepens the understanding and affiliation of that clinician, who inhabits the life and circumstances of his patient the way an author inhabits a character of his own creation. In Charon’s earlier work, this inhabitation of the other is connected to empathy, and many studies continue to investigate the potential of narrative medicine to foster and bolster empathic capacity. Later work in narrative medicine grapples with the phenomenological problem of empathy which Charon, in The Principles and Practice of Narrative Medicine, calls ‘a misguided assumption that one can enter into or know another’s experience’. In response, Charon and other scholars drew from moral philosophy the notion of intersubjectivity to better explain the relationality between patients and clinicians that is the goal of their work. DasGupta in particular explored this distinction in her work on narrative humility, which has informed much recent narrative medicine scholarship, especially in the areas of narrative social justice, structural competency, and abolitionist pedagogy. Narrative medicine’s engagement with issues of injustice, power dynamics, and structural inequality aligns quite closely with the project of the parallel chart, especially where its imaginative, collaborative qualities contrast with the supposed objectivity of the medical chart. When Mitchell writes about the prevalence of the ‘colorless, objective academic voice’ in clinical nursing notes, she situates it in the context of broader feminist critique of objectivity and the Enlightenment era roots of the positivist language that is so prevalent in the sciences. She argues that a voice that
Charon, ‘To Render’, pp. –. Charon, ‘To Render’, p. . Isabel Chen and Connor Forbes, ‘Reflective Writing and Its Impact on Empathy in Medical Education: Systematic Review’, Journal of Educational Evaluation for Health Professions, (). Charon, Principles and Practice, p. . Charon, Honoring, p. . Sayantani DasGupta, ‘Narrative Humility’, The Lancet, , (), –. Kevin J. Gutierrez and Sayantani DasGupta, ‘The Space That Difference Makes: On Marginality, Social Justice and the Future of the Health Humanities’, Journal of Medical Humanities, , (), –. Jonathan M. Metzl and Helena Hansen, ‘Structural Competency: Theorizing a New Medical Engagement with Stigma and Inequality’, Social Science and Medicine, (), –. Pooja M. Varman, Marcus P. Mosley, and Billie Christ, ‘A Model for Abolitionist Narrative Medicine Pedagogy’, Medical Humanities, , (), e.
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rejects the personal and the emotional in favour of the technical and biomedical leaches important meaning from narratives of patients and their caregivers and privileges the voices of the traditionally powerful. The same may be said of all clinical medical writing, and the parallel chart works against this damaging trend. Eschewing objectivity and analysing the written narrative as a creative text rather than a reflection of medical truth, parallel charting encourages participants to acknowledge their role as active creators of the narrative. For Wood, the exercise ‘recasts the studentdoctor as the “storyteller” of the hospital, insisting on his or her role as both reader and writer of the intricate dramas of daily life on the wards’. And further, the drama that is written features the clinician themself, exposed, as much a subject as the patient. ‘The patient’s biography is always braided with the student’s autobiography’, writes Charon. From the braiding of stories comes a recognition of shared humanity and a movement toward levelling the power discrepancy between clinician and patient as they collaboratively generate the text. Wood calls the co-creative relationship ‘interauthority’, a partnership in empathetic recollection and creation. Interauthority is impossible when the clinician maintains the distance and authority of being the objective voice, so bringing the clinician into reckoning with their own subjectivity lays the groundwork for affiliation. Both phases of the exercise – the creation of the text and the communal reflection on it – thus reinforce the shared subjectivity of clinician and patient. Reflection is a didactic function of the parallel chart, teaching participants to change their practice and become better clinicians. In a paper on writing pedagogy in medical education, Delese Wear and colleagues examine exercises like the parallel chart through the lens of education theorist John Dewey’s concept of reflection. Leading from puzzlement to transformative action, the process of reflective learning is necessarily a communal one that happens in sharing and revision. It can acclimate students to tolerating ambiguity, give them a sense of agency over their professional development, and inspire them to examine the sociocultural context and power structures of medicine. And though the written text of the parallel chart may never be shared with the patient directly, the
Kim M. Mitchell, ‘Academic Voice: On Feminism, Presence, and Objectivity in Writing’, Nursing Inquiry, , (), e. Wood, p. . Charon, Honoring, p. . Wood, p. . Delese Wear and others, ‘Reflection in/and Writing: Pedagogy and Practice in Medical Education’, Academic Medicine, , (), –. Wear, pp. –.
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The Parallel Chart as Medico-Literary Practice
patient is still a member of that reflective community. As Wood argues, clinicians who have worked on a parallel chart ‘bring its construction of the patient with them to their next encounter where it is “read” nonetheless. The student is in a constant process of revision in which the plot of the patient narrative is critiqued or read against each new experience of the patient.’ This cycle of reflection and transformation theoretically impels clinicians and trainees towards a clinical practice that is more fulfilling for providers and better serves the needs of their patients.
Practice In the years since its introduction, the parallel chart has been adopted and disseminated by many educators and researchers, taking on a multiplicity of forms and purported functions. Studies of the method investigate various possible beneficial effects, some of which hew closely to Charon’s original intentions and some of which venture into new territory. Some focus on trainees, as Charon did, and others on clinicians in active practice. Some applications of the parallel chart even alter or eliminate fundamental aspects of the exercise’s structure, raising questions about the defining boundaries of the form. This section explores a selection of the diverse progeny that have evolved from the parallel chart and the various ends their proponents seek. Though not one of Charon’s original goals, some seek to demonstrate that the parallel chart can help medical trainees and professionals develop and strengthen their sense of professional identity. Clandinin and Cave studied four Family Medicine residents in the United States, who completed one parallel chart entry each week for ten weeks and attended sessions every other week to share and discuss their work. Through close reading of the charts and the dialogues in the discussion sessions, the researchers found that the stories were shared into what they call the ‘storied landscape’ of the group. The narratives created an intellectual and moral context against which each doctor-in-training could set the meanings derived from their work, shaping ‘the lens through which he or she views each new clinical experience’. In a subsequent study, Clandinin and colleagues repeated the parallel chart practice with a group of eight Family Medicine and three Internal Medicine residents, finding
Wood, p. . D. Jean Clandinin and Marie-Therese Cave, ‘Creating Pedagogical Spaces for Developing Doctor Professional Identity’, Medical Education, , (), –.
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again that the practice enabled the participants ‘to shift those stories, to retell and relive who they are and are becoming as physicians in the making. As they compose their backward looking stories, they also begin to compose forward looking stories for themselves, stories of who they are becoming as physicians.’ These studies highlight the aspect of affiliation that Charon identifies as connection to the profession, but diverge from the explicitly relational goals of her original exercise. The Health and Wellbeing Area of the Istituto Studi Direzionali (ISTUD) Foundation in Milan, Italy, has conducted a number of studies of the parallel chart methodology, including the qualitative study of pulmonologists by Banfi and others, cited earlier. In all the ISTUD projects, the parallel chart exercise is fundamentally different from Charon’s initial concept in that the written portion is not a free response but is instead a series of short-answer questions and prompts. It also differs in that the narratives are collected and analysed by the researchers separate from any group discussion among the participants. Many of the studies enroll practising clinicians throughout Italy, so one can imagine the impracticality of arranging small-group sessions for such a busy and dispersed study population. The researchers acknowledge the limitation of structuring the responses with prompts, as it can reduce respondents’ ‘spontaneous expressions’, but note that the tool was designed to facilitate comparison of the narratives and give participants a less intimidating approach to narrative medicine than a blank page. The Milan group have looked at ways the parallel chart can protect professional identity in the face of burnout. A mixed-methods study led by Marini investigated the parallel chart narratives of Italian pain therapists. The parallel chart template was a fill-in-the-blanks folktale about a village of suffering people and those who came to help them. The researchers’ aim was to allow participants to explore the professional challenges they faced in a metaphorical and symbolic way. The completed stories were then analysed to examine the culture of the clinicians and their environment. Participants also completed a modified Maslach Burnout Index. As with other parallel chart studies, the researchers saw that the writing allowed writers to gain deeper awareness about their acts of care. They also noted
Jean Clandinin, Marie Thérèse Cave, and Andrew Cave, ‘Narrative Reflective Practice in Medical Education for Residents: Composing Shifting Identities’, Advances in Medical Education and Practice, (), –. Charon, ‘Attention’, p. . Paola Chesi and others, ‘Epileptologists Telling Their Experiences Caring for Patients with Epilepsy’, Seizure, (), – (p. ).
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The Parallel Chart as Medico-Literary Practice
that, for some participants, ‘[l]oneliness [was] permeating their stories’, and they suggest that narrative methods like the parallel chart could be a way to identify clinicians at risk for burnout and provide a way for them to rediscover the meaning in their work. In an interview on the ISTUD Narrative Medicine Blog, Paola Chesi, coordinator of the ISTUD Foundation’s Master in Applied Narrative Medicine programme, echoed these findings, explaining that narratives can be ‘a broader tool of awareness to recover motivation’, helping physicians ‘move from diffidence to curiosity’. Chesi has also studied the parallel charts of epileptologists. This methodology also used short-answer forms, but not in the context of a story. Each parallel chart consisted of twenty-six prompts such as: ‘The first time I met the person with epilepsy . . .’, ‘Her/his activities . . .’, ‘I felt . . .’, and ‘I think . . .’. Qualitative analysis of the responses demonstrated that parallel charting can give clinicians a broader view of their patients’ humanity and of the wider social context of diseases like epilepsy, which are associated with significant stigma. They noted that the absence of patient voices was a potential limitation of the research. As such, a multicentre study by Simonelli and colleagues had ophthalmologists, multidisciplinary healthcare professionals, patients, and patient caregivers complete a parallel chart project. While the form of the chart was the same prompted short-answer format as earlier studies, the inclusion of patients and caregivers in this research was novel. More than in other studies, the conclusions here focused on the organizational and institutional challenges patients face in accessing care, and the importance of multidisciplinary support. The researchers call for adjustments to the systems of care for patients with inherited retinal disorders, noting that the analysis of these narrative perspectives through the parallel chart highlighted areas for improvement that had been previously overlooked in analysis of the clinical pathways by traditional, non-narrative methods.
Critiques Criticism of the parallel chart falls largely into two domains: the practical and the theoretical. The obstacle most frequently raised by those who
Maria Giulia Marini and others, ‘Narrative Medicine to Highlight Values of Italian Pain Therapists in a Changing Healthcare System’, Pain Management, , (), –. Alexandra Fiorencis, ‘Parallel Charts: Interview to Paola Chesi’ [accessed May ]. Chesi, pp. –.
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study the parallel chart is the time it takes to complete. While writing a single page seems like a brief task, Banfi found that each charting exercise took thirty minutes on average, which means it would be difficult or impossible to implement it as a regular practice for every one of a busy clinician’s many patients. The authors do note in a correspondence that they have seen that with training the time to write a parallel chart decreases to ten minutes, so it could be more feasible to implement. In response to an inquiry about whether open notes could provide a similar benefit to parallel charting without the added time, Banfi and colleagues stressed the cathartic nature of the parallel chart entries for the clinicians. Some of the pieces, they explained, would not be suitable for patients to read, so the decision to share a parallel chart with a patient should remain up to the writer. The more fundamental critique of parallel charting is theoretical, based on Galen Strawson’s essay ‘Against Narrativity’, which disputes the twin theses that humans typically experience their lives as narrative and that experiencing one’s life as narrative is beneficial. In her piece ‘The Limits of Narrative’, Angela Woods brings to bear on narrative medicine the principles of Strawson’s argument, not in hostility, but as a provocation to think critically. While she does not address the parallel chart specifically, her discourse encompasses the practice. Upholding narrative as the prime mode of human self-expression, Woods contends, promotes a model of the self that is an ‘agentic, authentic, autonomous storyteller . . . who possesses a drive for storytelling, and whose stories reflect and (re) affirm a sense of enduring, individual identity’. This is not true of all individuals, as Woods asserts, because not everyone has both a ‘drive toward form-finding’ and a sense of continuous selfhood. Narrativity as it is practised in the medical humanities often functions to produce ‘Western middle-class, liberal and neo-liberal modes of being’, and limiting the field of medical humanities to narrativity risks shutting out the full diversity of perspectives and expressive forms. Despite recent trends to ‘overinflate’ what counts as narrative, she contends that forms of self-expression that do not rely on temporality to communicate a
Banfi, p. . Amir-Seena Saberi-Movahed, Syed Waqar, and Ahmad Salha, ‘Perspectives on Narrative Medicine’, International Journal of Chronic Obstructive Pulmonary Disease, (), –. Galen Strawson, ‘Against Narrativity’, Ratio, , (), –. Angela Woods, ‘The Limits of Narrative: Provocations for the Medical Humanities’, Medical Humanities, , (), –. Woods, pp. –.
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The Parallel Chart as Medico-Literary Practice
message (such as metaphor, phenomenology, and photography) are nonnarrative in nature and laudable alternatives to the widely accepted mode of written reflection. In direct response, McKechnie wrote ‘Anxieties of Communication’ in , countering that those supposedly non-narrative forms of expression are still fundamentally narrative in nature, as they evoke narrative engagement from their readers or viewers. She asserts that ‘non-verbal expression requires language and narrative ordering in the construction of expression and in the process of meaning-making’. Whether these non-traditional methods and forms can be conjoined with the practice of parallel charting could prove to be a fruitful area of exploration and inquiry.
Conclusion As a method of narrative medicine, and as a medico-literary practice, the parallel chart offers its practitioners a unique approach to encountering the humanity of their patients, building affiliation, and finding deeper significance in their work. It is a revolutionary method not only because of its innovations in medical humanities education, but also because of its effort to alter the balance of power in medical encounters. Clinicians writing a parallel chart are exposed in their fullness of interpretation, emotion, and humanity, co-creating a narrative that entwines their own subjectivity with their patients’. This process subtly relocates the sites of knowledge and authority away from clinicians to patients, from objectivity to subjectivity, and from biomedical positivism to narrative ways of knowing. The practice of parallel charting is fundamentally transformational and shows many potential benefits. Though some have critiqued its practicality and its focus on certain types of narrative forms, the parallel chart has proved to be highly adaptable. The practice has been implemented in various ways with different types of participants in varied settings, and its mutability gives it the vigour to remain a valuable tool for clinicians, educators, and all those who care about improving the state of healthcare around the world.
Woods, p. . Claire Charlotte McKechnie, ‘Anxieties of Communication: The Limits of Narrative in the Medical Humanities’, Medical Humanities, , (), –. McKechnie, p. .
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Articulating the Experiential in Graphic Medicine Kimberly R. Myers
The most fundamental connection between medicine and literature is that both are based on stories: the story a body tells; the story a patient tells based on their experience of disease in that body; the story a doctor tells in the medical chart about a patient; the stories that writers and the media tell about health and illness; the stories we have in our head about what medicine can do and how medical practitioners should interact with us in the twenty-first century; and the stories healthcare institutions create to market their services. Stories of medical practices, healers, and carers appear across cultures and throughout literary history, both oral and written. Traces of ancient stories find their way into our twenty-first-century pursuits of well-being, though we often do not recognize them or, indeed, even know they existed. For instance, the legacy of Shiva and Parvati, first passed down orally, then recorded in Sanskrit, and ultimately translated into romance languages, survives in contemporary practices of yoga and Ayurvedic medicine; the dialogues of the Yellow Emperor still inform herbalism and acupuncture; and Hippocrates’ beliefs about bodily humours are echoed in some cultures’ practice of cupping. Indeed, though the philosophies and approaches differ, the overarching goal of shamanic narrative rituals – e.g. healing the whole person – is not dissimilar to cutting-edge genetic interventions of personalized medicine. Perhaps more familiar are stories of illness and healing along the trajectory of Western literature: Grendel’s disarticulated shoulder in Beowulf; Guinevere pasting medicinal herbs on Lancelot’s wound; the open sore on the Cook’s leg in The Canterbury Tales; King Lear’s mental state as he rages on the heath; the ravages of venereal disease in Jonathan Swift’s ‘A Beautiful Young Nymph Going to Bed’; the moral and economic implications of tainted water in Henrik Ibsen’s An Enemy of the People; the narrator’s psychological struggle today associated with postpartum depression in Charlotte Perkins Gilman’s ‘The Yellow Wallpaper’; and, in more recent times, Cal’s intersexuality in Jeffrey Eugenides’ Middlesex.
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Articulating the Experiential in Graphic Medicine
Literary subjects are often rendered in visual art as well, and as one might expect, these drawings and paintings sometimes reveal aspects of health and illness. Conjure the image of Ophelia’s suicide in Millais’s eponymous painting, for instance, and consider how his model Lizzie Siddal’s addiction to laudanum played out in their Pre-Raphaelite community, influencing the content and styles of both its poets and artists. Curious readers often seek out visual images to help sharpen their understanding and the impact of the details a story presents. Take Maggie O’Farrell’s acclaimed novel Hamnet, whose protagonist, Agnes, cultivates and sells medicinal herbs and cares for her children in Stratford-upon-Avon while her playwright husband works mostly in London. Immersed in the particulars of English life O’Farrell offers, we learn about Agnes’s botanic arts – how much good they do and how, sadly, they fail to save her eleven-year-old son, who dies of bubonic plague. Searching for images of Elizabethan medicinal plants almost inevitably leads to Paulus Furst of Nuremberg’s depiction of Doctor Schnabel von Rom (Figure .). This image, in turn, propels readers back to narrative: Why is he dressed this way? What’s the medical reasoning behind his frightening mask? How were botanicals such as Agnes’s prepared and deployed to ward off the Black Death? Where might we find stories of real doctors and patients of this era in order to assess the efficacy of such ‘medicinal’ interventions? In this way, two mediums (the verbal and the visual) complement each other, providing a fruitful back-and-forth of questions and answers that yield stories – some historically accurate, some speculative. Notably, though, these two mediums do not function in tandem; each can stand – and perhaps most often does stand – alone. Comics work differently. Comics are, de facto, a hybrid medium in which verbal and visual storytelling work synergistically. Scott McCloud, widely acknowledged as the progenitor of comics theory, defines comics as ‘[j]uxtaposed pictorial and other images in deliberate sequence, intended to convey information and/or to produce an aesthetic response in the viewer’. In the discussion that follows, I aim to illustrate how the medium of comics enriches and expands the field of Medicine and Literature. While many of the themes that appear in written texts also appear in comics, the added dimension of visuality raises new questions and possibilities for extant conceptual and methodological approaches to the field.
Scott McCloud, Understanding Comics: The Invisible Art (New York: Harper Collins, ), p. .
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Figure . Doctor Schnabel von Rom () by Paulus Furst of Nuremberg
In the spirit of clarity, I should also explain that I come to this scholarship and pedagogy as one trained in literature who now teaches and conducts research in a college of medicine. From within the culture of medicine, I therefore always approach texts, visual or verbal or both, with an eye towards their aesthetic properties and their utility for teaching and practising clinical medicine.
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How Comics Work In comics, we apprehend verbal and visual meaning simultaneously; the two mediums work together to create a ‘third thing’ that surpasses either alone. That said, when seeking to understand this synergy more explicitly, it is helpful to separate out the visual and the verbal through a process of metacognition. Let’s begin with only the words from a given comics panel (Figure .). What story is being told in this text bubble? We understand that someone named Kimberly is receiving news, and the news ‘doesn’t look good’. But what might ‘it’ be? The possibilities are so plentiful that it’s almost ludicrous to speculate. As is common in comics, even the appearance of the words and the text bubble themselves contributes to meaning. What do we make of the way the text bubble and the words are drawn here? Does the tremulousness of lettering and outline image suggest that the speaker is perhaps quavering? Is the speaker emotionally shaky, or is the news itself somehow wavering and insubstantial? Perhaps the quivering is connected to how the words are heard by ‘Kimberly’? Whatever else is true, the visual appearance of the words conveys that something negative or frightening is afoot. Now, let’s take only a visual image from a comics panel (Figure .). To interrogate and interpret what we see here, it is helpful to use Visual Thinking Strategies, a democratic approach for appreciating and developing visual meaning-making. VTS, as it is commonly known, welcomes any and all ideas about a piece of visual art, asking participants three basic questions:
Figure .
‘This doesn’t look good’
Source: Graphic Medicine Manifesto, ed. by M. K. Czerwiec and others (University Park: Penn State University Press, ).
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Figure .
Desperate to escape
Source: Graphic Medicine Manifesto, ed. by Czerwiec and others.
. What’s going on in this picture? . What do you see that makes you say that? . What more can we find? While this sequence seems rather simplistic at first glance, it yields a kind of engagement that is multilayered and complex, particularly when facilitated by someone formally trained in the VTS process. Notably, our discussion of these questions here is necessarily briefer and more superficial than would be the case in an actual VTS discussion.
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In response to the first question, we might say that the figure, whom we read as female, is experiencing some kind of distress. We might further speculate about the relationship between her prone and upright positions – it appears that she visualizes herself sitting up quickly – and question what causes her to imagine a change in body position. What do we see that makes us say the figure is female? Evidence includes the relative smallness of her body, the upward slope of her chest, and perhaps her hairstyle. What do we see that makes us say the figure is in distress? Evidence includes the artist’s use of emanata (little lines and shapes that suggest motion or emotion and are not meant to be read as representing reality – e.g. drops of sweat bursting from the figure’s face in both the main image and the thought bubble); the figure’s trembling grip of the surface upon which she lies and the shaking of her lower body; the amorphous shape that hovers over and beside her; and the fact that her face is turned away from direct eye contact with this potentially humanoid ‘thing’. What leads us to believe that the figure is actively imagining herself in another, less restricted position? Two conventions of comics are at play here: the thought bubble, indicated by the cloud-like shape on the upper left and the small circles leading up to it from the figure’s head, and the emanata at her back that indicate movement. Imagining this image as if it were ‘real life’, we might conclude that the figure’s springing up from the surface indicates a surge of adrenaline and suggests an instinctive need to ready herself for whatever threatens her; operating from an upright position reduces one’s vulnerability. This process of providing evidence for our ideas about ‘what’s going on’ here is directly relevant to training in evidence-based medicine, the gold standard for medical practice in twenty-first-century Western medicine: every theory postulated must be backed up with proof in the form of concrete data so that a physician can create a reliable narrative to help the patient comprehend their illness. This story must also be as complete as possible, so it is important to avoid premature closure, or ‘anchoring bias’, in which one attends to subsequent observation only inasmuch as it confirms an original assumption/diagnosis. In comics, as in clinical medicine, persistent questioning is required for essential insight – a story that makes sense. So, what more can we find in this panel? We might wonder about the figure’s clothing (it appears loose and bulky), where she is located (it’s not
David L. Sackett, ‘Evidence-Based Medicine’, Seminars in Perinatology, , (), –.
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typical to lie on one’s back when someone is standing nearby – if the hovering shape is, in fact, human), and whether any other details might advance the narrative our minds have already begun to create from this panel (what’s that on her lapel?). Our responses to these three VTS questions probably lead us to believe that we understand the basic situation depicted in the drawing. Our confidence increases when we insert the text bubble that, with the image, comprises the actual comics panel as originally drawn (Figure .).
Figure .
Visceral response
Source: Graphic Medicine Manifesto, ed. by Czerwiec and others.
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When we apprehend visual and verbal messages simultaneously, our understanding is more immediate, intuitive, and complete. Swedish scholar Rune Pettersson provides valuable insight into this argument in ‘Verbo-Visual Communication’. What is especially helpful is his cogent bulleted list of major research findings in this dual-focus field. In verbal language, ‘[t]he perception of linear representations requires a slow and sequential processing for comprehension of content’, whereas visual ‘[p]erception of two- or three-dimensional representations entails fast, parallel, simultaneous and holistic processing’. Indeed, ‘[i]t may take only – seconds to recognize the content in an image . . ., but – seconds to read a verbal description of the same image’. This difference is attributed to the fact that ‘[v]isual languaging abilities [i.e. the ability to understand visual language] develop prior to, and serve as the foundation for, verbal language development’. Further, in verbal language ‘[t]here is no direct correspondence between groups of letters, words and reality. Each meaning is defined and must be learned.’ By contrast, ‘[v]isual languages attempt equivalence with reality. Visuals are iconic. They normally resemble the thing they represent.’ One caveat, however, is that although visual ‘[m]eaning is apparent on a basic level, . . . the visual language must be learned for true comprehension’, as: ‘There are major differences between the concepts of “seeing”, “looking” and “reading”.’ While a discussion of these distinctions is beyond the scope of this paper, it is worth noting that they impact the effectiveness of the VTS process. These variations in apprehension and encoding/decoding have implications for remembering information as well. Pettersson concludes that ‘[m]emory for pictures is superior to memory for words . . . [which is called] the “pictorial superiority effect”’ and that ‘[m]emory for a pictureword combination is superior to memory for words alone or pictures alone’. Proof of Pettersson’s findings comes to light somewhat humorously when we contrast the + words it has taken to explain his ideas with the single panel by graphic medicine co-founder M. K. Czerwiec (Figure .):
Rune Pettersson, ‘Verbo-Visual Communication’, in th International Research Symposium on Visual Verbal Literacy Process and Product: Media Education in Praxis (Deventer, Holland: International Visual Literacy Association, ). Note that for the sake of readability, authors of the multiple studies cited by Pettersson are not cited in-text with Pettersson’s precis. Pettersson, p. . Pettersson, p. . Pettersson, p. . Pettersson, p. . Pettersson, p. . Pettersson, p. . Pettersson, p. . Pettersson, p. . Pettersson, p. .
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Figure .
Your brain on comics
Source: Graphic Medicine Manifesto, ed. by Czerwiec and others.
It turns out that a picture really is worth a thousand words – or at least a few hundred! – again, a key way in which comics expand the field of Medicine and Literature.
Origins and Commitments of Graphic Medicine When comics convey stories of people who experience challenges to wellbeing – whether from the perspective of patients, healers, or carers – we find ourselves in the domain of graphic medicine, a relatively new – or formally named, at least – genre. Ian Williams, MD, coined this term in when, as a primary care physician in rural Wales and comics artist who was pursuing postgraduate study in fine arts and medical humanities, he launched the Graphic Medicine website. This site became, and remains, a gathering place for people interested in the ‘intersection of the medium of comics and the discourse of healthcare’, as the term is defined in the Graphic Medicine Manifesto, a book that lays out core intentions and practices for the field. The Manifesto also, and importantly, stakes the claim that graphic medicine is a political enterprise that deliberately eschews normative assumptions in medicine – for instance, that of a universal subject (i.e. that a single kind of person can represent an ‘essential’ reality of being a patient or being a doctor) and that of an objective practice (i.e. that medicine entails clear-cut procedures and yields unambiguous data that result in unequivocal ‘truth’). Instead, the graphic medicine movement is
Graphic Medicine Manifesto, ed. by M. K. Czerwiec and others (University Park: Penn State University Press, ), p. .
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democratic in its inclusivity of multiple subjects whose points of view and experiences can be provocative and contradictory. This multiplicity invites lively exploration and debate instead of comfortable answers. Graphic Medicine Manifesto’s bold, even in-your-face, proclamation is, in part, a response to the way comics as a medium has been construed historically, and it signals why graphic medicine has only relatively recently been accepted as literature proper in most literary and cultural studies circles. In his Manifesto origin story, Ian Williams discusses how comics have been viewed as transgressive, remaining mainly underground except in ‘seedy “alternative” book shops that seemed to specialize in pornography and occult literature’. Similarly, in their scoping review of the use of comics in health education, Harvard librarians Matthew Noe and Leonard Levin mention the ‘“comics scare” of the s’ as fomented by ‘psychologist Fredric Wertham’s book, Seduction of the Innocent’. Not only were comics viewed as morally questionable, they were also considered aesthetically lowbrow. Even McCloud once deemed comics ‘crude, poorly-drawn, semiliterate, cheap, disposable kiddie fare’. Though McCloud’s and Will Eisner’s foundational theoretical work on comics helped turn the tide in the early to mid-s, undesirable connotations with the word ‘comics’ persist even now – to wit, the debate within the graphic medicine community over whether to use the term ‘graphic’ or ‘comic’. Some fear the latter designation risks trivializing our work or dismissing it outright as non-academic. The former term ostensibly provides a degree of legitimacy by grafting onto the relatively recent resurgence of ‘graphic fiction’ and the ‘graphic novel’, terms that signal respectable ‘literature’. Noe and Levin, however, point out that avoiding the term comic ‘creates significant problems in discoverability’ for professionals who catalogue the work and for readers who want to access it. They therefore argue that ‘all future publications in this area [should] include the word “comic” in the title, abstract, and/or keywords to improve discoverability and help eliminate confusion surrounding the medium’. With regard to the respectability of ‘comics’, the connection to medicine has likely helped legitimize the genre. In turn, comics have
Ian Williams, ‘Comics and the Iconography of Illness’, in Graphic Medicine Manifesto, ed. by Czerwiec and others, pp. – (p. ). Matthew N. Noe and Leonard L. Levin, ‘Mapping the Use of Comics in Health Education: A Scoping Review of the Graphic Medicine Literature’, Graphic Medicine [accessed June ] (p. ). McCloud, p. . Noe and Levin, p. . Noe and Levin, p. .
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helped advance the field of narrative medicine by adding a new and independent modality (visual) for appreciation and understanding of clinical stories. So why are comics so appealing in the domain of medicine? Perhaps the primary reason is the context in which medicine is learned and practised. Medicine is extremely fast-paced; there is little time to accomplish all the tasks that need to get done, and there’s even less time for reflection. A popular metaphor for education and work in medicine is that it’s like ‘trying to drink water from a firehose’. Communication among members of this culture – excepting communication with patients – is intentionally direct and succinct, the briefer the better. Understandably, then, the concision of comics is appealing to both doctors and medical learners; meaning can often be more immediate and intuitive than when presented in either words or images alone, as we’ve seen. The visual appearance of comics itself is also appealing, signalling something ‘different’ that promises a welcome respite from lengthy articles, densely detailed graphs, and tedious, characterless electronic charting. Another advantage of comics in the culture of medicine is that they alleviate pressure to be the smartest person in the room. As cartoonist Chris Ware says, ‘[y]ou don’t blame yourself for not “getting” a comic strip – you usually blame the cartoonist’. Even to the extent that the older, dimmer view of comics as ‘semiliterate’ and ‘kiddie fare’ survives, an upside is that comics are associated with play, the antithesis of homework and professional productivity.
Comics’ Contributions to Healthcare Providers’ Knowledge, Skill, and Empathy Apart from the merits of comics in the broader culture of medical education and practice, the comics medium promises various benefits for one-to-one clinical encounters. Consider what we, all consumers of healthcare, want and need our physicians and other healthcare providers to utilize on our behalf: knowledge, skill, and empathy. In order to carry out whole-person healing, our providers need factual knowledge of human biology, anatomy, and physiology; the skills to operationalize that knowledge, including, for instance, how to tailor diagnostic and therapeutic options to a given patient’s insurance status and ability to adhere to a treatment regimen; and empathy, an ‘affinity with’ patients that manifests
Chris Ware, ‘Comics Words’, Smokyland [accessed June ].
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in benevolent action and perhaps (but not necessarily) also emotional connection. To prepare students for what a clinical encounter with an individual patient will entail, medical teachers favour case-based education. ‘Cases’ are particularly helpful because information is conveyed in the form of a story and, as the medical literature demonstrates, information presented in a specific story is more likely to stick than information presented in abstraction. Cases come to life and therefore become even more memorable when ‘standardized patients’ (SPs) tell their stories ‘live’, as it enables learners to practise close listening and visual observation, and analyse the patient and their ‘presentation’ as a whole. In addition to the verbal information they have heard, learners remember an SP’s facial expressions, body language, features such as hair colour and style, and even choice and appearance of clothing. As we have seen above, the visuo-verbal nature of comics makes them perfect for such multimodal input (recall Figure .) and much simpler to provide than SPs. In comics, verbal and visual stories come together in a single ‘person’/character, so the information is more holistic and less artificially disconnected than details presented in a written case that is merely accompanied by images of a de-identified patient whose whole body rarely appears. (Typically, only the body parts germane to the case at hand are presented in an image that accompanies a case.) To be sure, comics do not replace the need for focused observation of actual clinical images, but they do often manage to convey more about the individual person as a whole. Consider the following excerpt from ‘Sneaking Suspicion’, a comic that probes the complexities of reporting child abuse (Figure .). This panel conveys important information about where to palpate the face of a child (here, six-year-old Hannah) who presents with a painful bump and bruise on her nose. Subsequent panels reveal necessary components of a physical exam in the context of potential abuse: scrutinizing back, skin, tummy, and limbs, for instance (Figure .). More than just procedural considerations about what to look for and how to perform a thorough physical exam, these panels also reveal critical information about Hannah’s overall well-being, which factors into Dr Blanchard’s assessment of the likelihood of abuse. Note Hannah’s dishevelled dress and unkempt hair (more apparent in the comic as a
Daniel M. Keller, ‘Comic Strips Carry Serious Messages for Medical Students’, Medscape Medical News, March [accessed June ]. Kimberly Myers, Molly L. Osborne, and Charlotte A. Wu, Clinical Ethics: A Graphic Medicine Casebook, illust. by Zoe Schein (University Park: Penn State University Press, ), p. .
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Figure .
‘Does it hurt here?’
Source: Clinical Ethics: A Graphic Medicine Casebook, ed. by Kimberly R. Myers and others (University Park: Penn State University Press, ).
Figure . Checking for other injuries Source: Clinical Ethics: A Graphic Medicine Casebook, ed. by Kimberly R. Myers and others (University Park: Penn State University Press, ).
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whole) but also her eager responses – both the speed with which she replies and her light-hearted behaviour as conveyed by the exclamation mark following her ‘OK!’ to be examined. Hannah not only maintains eye contact with Dr Blanchard but indeed seems quite taken by her beloved pediatrician whom, we infer, she trusts. Also evident is the way Dr Blanchard balances the need to conduct a thorough exam of her patient with the need to minimize the escalating anger of Hannah’s father. We can see his vexation build as we move from the last image in the first row, where his brow is furrowed in the middle but still horizontal, to the first image in the second row, where his frown is more pronounced and mouth open as if to speak, and finally, to the last panel, where his words and the emanata indicate that he is now shouting. This sequence calls our attention to comics scholar Susan Squier’s observation that ‘the medium of comics represents time spatially’. Discussing Rita Charon, MD’s perceptions of diachronic time (‘the perception of time as a flow within which the narrator experiences his or her embodied self’) and synchronic time (‘simultaneous or all-at-once’) in the practice of narrative medicine, Squier concludes that: Panels combining images and words can represent events synchronically even as the textual narrative of the comic is floating down the diachronic river. While narrative medicine focuses on the textual and verbal, graphic medicine can access those aspects of illness and medicine that we experience visually and spatially, as enduring, if intractable, aspects of the patient [and here the doctor] experience.
Comics’ ability to indicate the passing of time in this way is unique and, as such, is an important augmentation of Medicine and Literature as well as a parallel field in its own right. Arguably the most basic skill a physician must possess is the capacity for critical thinking, and comics are excellent tools for practising the process. A co-founder of graphic medicine, Michael Green, MD, provides helpful insight into the benefits of the ‘incomplete visual and written accounts’ inherent in comics: The reader must stitch together pictorial and textual clues, filling in the blank space between panels to determine what happened, when it occurred, and over what duration. . . . The reader must apply experience, skill, and knowledge to both complete the story and convert it into a coherent
Susan Merrill Squier, ‘The Uses of Graphic Medicine for Engaged Scholarship’, in Graphic Medicine Manifesto, ed. by Czerwiec and others, pp. – (p. ). Squier, p. . Italics added.
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. narrative. The act of reading comics critically can make explicit the processes by which the reader is an active participant in the story; this also helps students understand diagnostic reasoning, an activity that likewise involves attention to words (the patient’s version of the medical history) and visuals (the physical findings, nonverbal cues, etc.).
In something of both echo and extension of Green’s explanation, Ian Williams reveals how comics, like more traditional ‘literature’, also foster empathy: ‘Comics demand reader participation – inviting readers to empathize with a subject by entering its world and seeing through its eyes – and enable the reader to gain insight from the vicarious experience.’ An excellent illustration of empathic understanding occurs in ‘In Tolerance’ (Figure .). The protagonist, Sue Evans, is not very likeable, at least initially. Sue is an Army veteran who suffers from chronic pain and PTSD, and her abrupt demand for more pain pills leads the oncall doctor at her primary care practice to dismiss her as ‘another difficult patient’ whose ostensible drug-seeking behaviour points towards ‘overmedicating’, frank addiction, or even possibly ‘selling drugs on the street’. We see Dr Sloan’s doubts materialize in multiple thought bubbles whose images create mini-narratives for us to contemplate. Through the lens of Dr Sloan’s training and experience, we understand more clearly that she is not merely unsympathetic; rather, she is responsible not only for the health of an individual patient but also the well-being of the community outside the clinic. That said, we witness Sue’s genuine misery as depicted in her facial expression, posture, and overall comportment, realities that we might not be able to realize in the same way in a purely verbal description of Sue. Dr Sloan’s request for a urine sample is the last straw for Sue, who storms out exasperated that ‘I’m in real pain and you don’t trust me!’ Sue returns a week later when her own primary care physician, Dr Ruiz, is back in the office. Dr Ruiz invites Sue to ‘tell me a little more’ about what’s been going on and learns not only that Sue’s pain is intractable – likely due to a developed tolerance for the medicine she’s been taking – but also that her father has recently died and that she’s experiencing insomnia, night terrors, and depression. As Sue’s story unfolds, Dr Ruiz visualizes the details of Sue’s lived experience of PTSD (Figure .).
Michael J. Green, ‘Graphic Storytelling and Medical Narrative: The Use of Comics in Medical Education’, in Graphic Medicine Manifesto, ed. by Czerwiec and others, pp. – (p. ). Williams, p. . Myers and others, pp. –. Myers and others, p. . Myers and others, p. . Myers and others, p. .
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Figure .
PTSD
Source: Clinical Ethics: A Graphic Medicine Casebook, ed. by Kimberly R. Myers and others (University Park: Penn State University Press, ).
We too now realize the external forces acting upon Sue. Social, political, and narrative constructs have helped shape who she is and how she is perceived by the professionals who have potential to heal her. Viewing Sue through Dr Ruiz’s eyes, the reader shares in the physician’s compassion in the face of their [sic] patient’s psychological torment and physical pain.
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Comics’ Contributions to Professional Identity Formation and Activism Comics also serve as guides for healthcare providers’ self-reflection, selfawareness, and Professional Identity Formation (PIF) – medicine’s answer to Victorian literary essayist John Henry Newman’s The Idea of a University: become your own best self, through rigorous, wide-ranging education, not only for enlargement of one’s own mind but also for the betterment of other individuals and society as a whole. For instance, ‘Battered Trust’ illuminates the soul-wrenching impact of a medical mistake on a patient’s family, yes, but here even more so on the physician who makes it. Dr G fails to see a red-flag risk factor in his patient Mary when he works her into his impossibly busy schedule for physical exam following a car accident. Though ‘everything looks good’ upon exam, Mary, a decades-long patient of Dr G, nevertheless later dies from complications of the crash. Dr G is devastated by this turn of events and is left to contend with the family’s rage, their threat of lawsuit, and his own guilt (Figure .). Note the way words and images suggest the tone and rhythm of the clinical visit with Mary’s daughter and son-in-law, particularly how emotional modulations and silence are conveyed via the use of negative space. Not all PIF lessons conveyed in graphic medicine are so sombre. In fact, some artists embrace the traditional association of comics with humour. We discover this in ‘The Swan’, a real-life account of how a busy doctor’s multi-tasking results in botched communication and ensuing terror for a patient and his wife. Distracted by the hospital pages he’s receiving on his phone, Dr Bennett nevertheless attempts to consent Mr Porter for placement of a pulmonary artery catheter, also known as a Swan-Ganz catheter, as named for its inventors. Time is of the essence here, as it always seems to be in medicine, and Dr Bennett inadvertently lapses into the medical jargon he uses with colleagues, absent-mindedly telling the Porters that ‘we can put the swan in your chest’ (Figure .). The panic that follows reminds Dr Bennett (and the reader) that obtaining informed consent entails more than procuring a signature on a legal form filled with dense text: lesson learned and, according to one of the authors of the comic, never forgotten.
John Henry Newman, ‘Discourse : Knowledge Viewed in Relation to Professional Skill’, in The Idea of a University (London: Aeterna Press, ). Myers and others, pp. –. Myers and others, pp. –. Myers and others, p. .
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Articulating the Experiential in Graphic Medicine
Figure .
Acknowledgement and plan
Source: Clinical Ethics: A Graphic Medicine Casebook, ed. by Myers and others.
‘Sneaking Suspicion’, ‘In Tolerance’, and ‘Battered Trust’ are implicit calls to action, a dimension of medicine we probably do not consider very often in our daily pursuit of good health. However, when we see situations that might contribute to disasters, much less tragic outcomes themselves, we demand improvements; when we see skill, wisdom, and compassion, we strategize how we can access similar quality of care for ourselves and the ones we love. In this way, comics demonstrate the ‘critical entanglement of literature and medicine’, the primary focus of the current Cambridge Critical Concepts volume. The three comics discussed here appear in the flagship publication of the new field of graphic ethics. Clinical Ethics: A Graphic Medicine Casebook is the first book of its kind, providing a
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Figure .
Imagining literally
Source: Clinical Ethics: A Graphic Medicine Casebook, ed. by Myers and others.
substantive exploration of clinical medical ethics in comic form. Part of the Clinical Ethics project – and graphic medicine in general – is to illuminate how medicine is shaped by texts and images in print, analogous to how medicine is shaped in and by mass media. As such, this fully enmeshed, entangled, and interdisciplinary genre is well suited to twentyfirst-century pedagogy and scholarship.
Comics and Individual Illness Comics are used by and on behalf of patients in myriad ways. Indeed, the majority of the graphic medicine literature addresses the subgenre known as graphic pathography – that is, stories of illness in comic form. While a full discussion of the subgenre is beyond the scope of this chapter, it is important to note that graphic pathography provides a different authorial position from which to consider the literature-and-medicine movement and is arguably the most common form of graphic medicine. It is easy to understand why this is the case. Telling stories of illness often comes
See Myers and others.
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naturally, as when we check in with close friends and family about what’s going on in our daily lives. To the best of our ability, we create narratives for our healthcare providers – when symptoms began, what hurts, and how it hinders our daily activities – in order to co-create a fuller story: what has caused this dis-ease, what can we do to make it better, and where do we go from here? Other reasons for telling a story of illness might not seem as obvious, but they are equally vital. According to Ian Williams, graphic pathographies ‘stem precisely from the need to express oneself’. More specifically: ‘Making autobiographical comics is a type of symbolic creativity that helps form identity – a way to reconstruct the world, placing fragments of testimony into a meaningful narrative and physically reconstructing the damaged body.’ In this way, graphic pathographies – the process of creating them, the artifacts themselves, and the act of reading them – can help transform stultifying dimensions of illness into lifeaffirming innovation. First-person perspectives on illness can also provide a sense of community and thus function as a kind of virtual support group that mitigates the isolation that all too often accompanies illness. An individual might come to see that others know what I’m feeling and have hope that if they can survive and flourish, so can I. Another form of empowerment fuelled by graphic pathography is patient education and the multiple benefits that flow from understanding not only difficult circumstances, but also unknown terminology and unfamiliar or complex medical interventions like imaging studies and treatment modalities. An excellent illustration of comics’ capacity to clarify important medical concepts is a series of panels in Marisa Acocella Marchetto’s Cancer Vixen, in which she depicts the extravasation that can result from chemotherapy. As Michael D. F. Goldberg and I discuss elsewhere: While patients might be told that chemicals can leak and damage tissue, the comic conveys specific implications of what that possibility might look like in real life. For Marchetto, this single side effect could cause permanent disability because she creates comics for a living. Fuller comprehension of the implication of extravasation might suggest to a reader of Cancer Vixen critical questions worth pursuing with her own physician before beginning treatment. . . . Readers can learn practical, even technical, information in the privacy of their own homes as they view panels at their own pace. They can think about what they see, they can research terminology, and they can
Williams, p. .
Williams, p. .
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. take the book with them to their next doctor’s appointment to ask for clarification.
Some artists might have an additional incentive to create a unique ‘iconography of illness’: ‘to challenge the “medical” authority from which the author feels excluded’ and thereby ‘reclaim [their bodies] from the hands of the healthcare professionals’. As with narrative medicine, a core tenet of graphic medicine is that patients’ voices must be heard and respected. But even with the best intentions, patients’ voices are often marginalized or absent from the narratives (re)created by doctors. Refashioning a patient’s story into objective, universally agreed-upon terminology is both necessary and beneficial to the patient, as it enables clear communication among care providers who must work as a team on the patient’s behalf. The danger comes, however, when the patient is ‘refined out of existence’, to use novelist James Joyce’s image of ‘the author’ in modern literature. At this point, medically speaking, a ‘person’ is reduced to mere ‘body’, and ‘well-being’ becomes primarily a matter of diagnosing and prescribing. An individual who experiences illness cannot afford to be, like Joyce’s author, ‘invisible’ or ‘indifferent’, as our stories of illness cannot be compartmentalized away from our identities. This is why it is critical for writers and artists to represent the ‘raw veracity of lived experience’ so that fellow sufferers and healthcare providers continually benefit from fresh insights. Graphic pathography has the capacity not only to reflect lived experiences of illness and the societal mores surrounding them, but also to shape those same realities. Ian Williams says it best in his discussion of the iconic work of comics: Images do not just ‘mirror’ the world; they help build it. . . . Iconographic representations of health, illness, and disease . . . help construct the illness stereotypes that influence the way in which a condition is viewed by others as well as the patient’s experience of the condition. . . . In constructing new visual styles of suffering and illness, therefore, the authors of graphic pathographies might be subtly altering the discourse of health and the social mediation of illness outside of the clinic.
In this way, graphic medicine enriches the field of Medicine and Literature by providing an additional (visual) modality for understanding.
Kimberly R. Myers and Michael D. F. Goldenberg, ‘Graphic Pathographies and the Ethical Practice of Person-Centered Medicine’, American Medical Association (AMA) Journal of Ethics, (), – (pp. –). Czerwiec and others, ‘Introduction’, in Graphic Medicine Manifesto, ed. by Czerwiec and others, pp. – (p. ). Williams, p. . Williams, p. . Williams, p. . Williams, p. .
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Articulating the Experiential in Graphic Medicine
As a field, graphic medicine is recalibrating and reinvigorating the literature and medicine connection, in large part because its inherent visuality positions literature closer to the practice of clinical medicine. Graphic medicine also enjoys a vibrant community and an increasingly robust scholarship. Two exciting trends from the frontier of graphic medicine are ) medical students and providers creating their own comics as means of, for instance, processing the varied challenges they experience but are forbidden to discuss with anyone outside a patient’s care team and ) mixed-methods research on the benefits of using comics directly with health providers, patients, and their network of support persons. For these initiatives, as with all creative, scholarly, and pedagogical enterprises in graphic medicine, ‘[w]e want our work to challenge accepted conventions of scholarship, merging the personal with the pedagogical, the subjective with the objective – the image with the text!’
Daniel R. George and Michael J. Green, ‘Lessons Learned from Comics Produced by Medical Students: Art of Darkness’, Journal of the American Medical Association (JAMA), , (), –. Kimberly Myers and others, ‘Use of a Graphic Memoir Enhances Healthcare Providers’ Understanding of and Empathy for Patients with Parkinson’s Disease’, The Permanente Journal, , (), –. Czerwiec and others, ‘Introduction’, p. .
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Applications: Politics
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Malaria Literature (Post)Colonial Perspectives, Infection, and the Question of Mobility Jessica Howell and Oishani Sengupta Tārāshankar Bandyopādhyāy’s novel Ārogya-niketan () takes place in the small village of Devipur, in West Bengal around the time of Independence. Tārāshankar shows the competitive yet interdependent relationship between allopathic and ayurvedic medicine by depicting a professional rivalry between Pradyot Sen and Jibon Moshāi, an elderly doctor practising indigenous medicine in Devipur’s clinic. Late one night, a sleepless Pradyot dāktār sits on his verandah, contemplating his role in the village as well as the outcome of two cases he has recently treated. This scene provides insight into his inner thoughts, within a novel that is largely focused on Jibon Moshāi. Rather than feeling assurance in the superiority of his ‘modern’ knowledge and the techniques he has acquired from reputed colonial-era institutions such as R. G. Kar and Calcutta Medical College, Pradyot faces a crisis of confidence. His concern allows the reader to reflect on the gap between the hubris of Westernized medical practice and the difficulty and complexity of controlling malaria in Bengal. The author of Ārogya-niketan, Tārāshankar Bandyopādhyāy (–), was a celebrated author and anti-colonial activist of twentieth-century
Tārāshankar Bandyopādhyāy, Arōgya-niketan, st ed., (Kolkata: Prakāsh Bhavan, ). . Sections translated by Oishani Sengupta. We follow the Bengali tradition of using the author’s first names within this chapter. According to Projit Mukharji, the term dāktār is a vernacularization of the English ‘doctor’. Dāktārs were not from ‘a single homogenous group’ (p. ). Rather, after the s, the term generally referred to South Asian, often Bengali, ‘people who were thought to practice “western” medicine’ (p. ). The role of the dāktār was of ‘crucial importance’ in Bengal (p. ). Though ‘they may feature only marginally in the government archives,’ he writes, ‘for the majority of rural Bengal . . . they were the living face of dāktāri medicine’ (p. ). Dāktārs’ intimacy with rural populations disproves any idea that ‘“western” medicine in India’ was ‘cocooned in “enclaves”’ (p. ). Mukharji discusses the significance of Ārogya-niketan (The House of Healing) in his history of dāktāri medicine (p. ). Projit Bihari Mukharji, Nationalizing the Body (New Delhi and London: Anthem Press, ). Also see Projit Bihari Mukharji, ‘Subaltern Surgeries: Colonial Law and the Regulation of Traditional Medicines in the British Raj and Beyond’, Osiris, , (), –.
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Bengal. His work provides critical perspectives of evolving social issues in pre- and post-Independence India. Ārogya-niketan presents a picture not only of the arrival of modern medical amenities in village communities but of their social and psychological impact, the challenges of building trust, and the resilience of established customs and faiths. Through the liminal figure of the dāktār and his relationship with the ayurvedic healer, in Ārogyaniketan, Tārāshankar carefully unpacks the legacies of colonial medicine in Bengal. The chronic or unpredictable nature of malarial illness creates a rhythm of household visitations. These repeated visits build intimacy and form an interdependence between the dāktār and his patients. Though colonial medicine may have presented the prevention and cure of malaria as absolutes, this novel shows that the dāktār’s treatment is a gradual process, connected to indigenous healing, and based in social relationships. British colonial ideology insisted that medical knowledge could be standardized and instilled in colonized populations; however, Tārāshankar’s novel illustrates that Western medical training was redefined and appropriated according to different locations and cultural values. The novel’s implied critique stems from its recognition that a top-down paternalist and interventionist approach is inadequate to the realities of, in this case, a rural Bengali environment with its own deeply held practices of healing. Tārāshankar sets the stage for Pradyot’s moment of self-reflection by surrounding him with images of malaria prevention: Pradyot dāktār was sitting on the verandah. . . . There were a lot of mosquitoes around. People said, if you sleep without a mosquito-net, the mosquitoes might collectively carry you away . . . Hay soaked in carbolic
As Poonam Bala has observed, indigenous medicine was highly professionalized and autonomous before the advent of the ‘profession’ of medicine inculcated by colonial education. Poonam Bala, Imperialism and Medicine in Bengal: A Socio-historical Perspective (New Delhi: Sage Publications, ), p. . Tārāshankar’s Arōgya-niketan builds on earlier representations of the dāktār in Bengali literature, such as Mānik Bandyopādhyāy’s Putul Nacher Itikathā (). By the s, medicine had become central to the leisure class’s project of acquiring professional and social respectability within a colonial context – in Arōgya-niketan, Jibon Moshāi’s own son goes to Kolkata to become more of an anglicized Babu instead of training under his father. The family’s conversation about where he will attend school assumes that medical training can be obtained as a mere gloss on social standing, as the Dr R. J. Kar Medical College hands out MB degrees to ‘ill-educated, financially struggling young men’ (p. ). The family laughs together that there is ‘there’s no need to pass’ (p. ) at this medical school. For an in-depth analysis of the contemporary legacies of colonial medicine in India, in the form of neoliberal medical practice that ‘trims public health into a series of centralized, single-axis initiatives’, see Towards a Critical Medical Practice: Reflections on the Dilemmas of Medical Culture Today, ed. by Anand Zachariah, R. Srivatsan, and Susie Tharu (New Delhi: Orient BlackSwan, ), p. .
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Malaria Literature
acid has been spread below the verandah on all sides. D.D.T and bleaching powder too. Snakes and pests don’t come close.
The scene mixes medicalized explanations about malaria prevention with community explanations, demonstrating that such categories of knowledge are not separable. Malaria prevention stems from an exercise of imagination as much as from science. In order to avoid the ‘single mosquito’ that ‘might carry the germ of malignant malaria’, Pradyot’s house is surrounded by chemical and physical barriers. This scene compounds control measures one upon another, seemingly creating an environment where no mosquito should be able to enter, while stressing that only a single mosquito is needed to cause illness. The passage implies that mosquitoes are remarkably resilient and mobile, evading a multiplicity of preventions offered by Western science. Further, without access to widespread laboratory testing to detect the type of malarial infection, the disease can continue to show clinical mutability and unpredictability. Therefore, the ‘best practices’ of allopathic medicine are inadequate to address rural health. Pradyot encounters this challenge when he loses a boy to death from malaria: ‘Where did he go wrong? From the beginning? In the diagnosis? It was true. He thought it was malaria. But it was malignant malaria. He’d made a mistake there. He had given a quinine injection. There was a result but it wasn’t permanent. It should have been intravenous’. The boy’s death causes Pradyot to feel professional insecurity as well as personal responsibility. Further, within the opening passage, there is a slippage between thirdand second-person pronouns, singularity, and collectivity. The shift from ‘Pradyot dāktār was sitting’ to ‘if you sleep without a mosquito-net’, implies a fluid movement from external description to internal thought, forming a free indirect style. There is also a seamlessly shifting scale between singularity (‘Pradyot dāktār’, a ‘single mosquito’) and collectivity (‘people said’, ‘mosquitoes might collectively’). On one hand, this s novel seems to include elements of realism – it presents social values, conflicts within relationships, and medical issues and treatments that affect community health. However, the work also highlights how realism itself, specifically medical realism, is a historical and cultural construct. Instead, Tārāshankar shows the artificiality of separating forms of medical knowledge, as well as the impossibility of trying to master one’s surroundings,
Bandyopādhyāy, pp. –. Bandyopādhyāy, pp. –.
Bandyopādhyāy, pp. –.
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by highlighting how mosquitoes blur the boundaries between one and many, body and environment. While his crisis of confidence calls into question colonial medical hubris, at the same time Pradyot dāktār’s obsession with chemically controlling mosquitoes is a direct reference to the history of malaria eradication under the British government. Literary accounts of the mosquito and its unsalutary effects on human populations in Bengal draw upon and reinterpret nonfictional genres such as policy documents, public health treatises, and scientific essays. Texts like Ārogya-niketan both cite and resist the conclusions of colonial medical discourse, which coded zones as disease-ridden to justify increased surveillance and extreme scientific experimentation. Through Pradyot’s struggles with quantifying and eradicating illness, the reader encounters the fractures in colonial medical logics. Western medical discourse glossed over the inequity and cultural and physical violence perpetuated by colonial domination, which made recommended medical practices unachievable. Tārāshankar draws upon the cultural history of Bengali writings by Rabindranāth Tagore that highlighted this disingenuous colonial logic. While Ārogya-niketan focuses on the impossibility of physically capturing mosquitoes and curing malaria, Rabindranāth and other latenineteenth and early-twentieth-century Bengali authors use formal innovations within their poetry and fiction to subvert the possibility of not only physically but also conceptually ‘capturing’ the mosquito. In other words, this chapter treats the mosquito not just as a figure, but as an optic. By using the mosquito to experiment with scale, the Bengali authors whose work we examine question the bases of Western rationality. The mosquito highlights shifting thresholds of observation, allowing the reader to experience how Western medical perception, characterized by realism, quantification, and control, falls short of understanding the human–non-human interrelationship. Such experimentation invites scholars of literature and medicine to nuance their understandings of ‘realism’ in terms of its anchoring in Western epistemologies. This chapter specifically focuses on the conceptual mobility of malaria, as related to experimentation with scale in fiction and poetry. Though early-twentiethcentury Western science may have focused on narrowing the meanings of malaria, in order to demonstrate that the disease was controllable, the
As Rohan Deb Roy demonstrates, the early decades of the twentieth century showed a ‘shift in the meanings of malaria: from being an elusive and generic cause of many diseases to its reconfiguration as the name of a mosquito-borne parasitic fever disease; from being an essential theme in asserting colonial difference and governance to emerging as an agenda in nationalist reconstruction and
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Malaria Literature
close analysis of Bengali literature preceding Tārāshankar’s novel shows a long-standing resistance to such neat categorizations of meaning. Furthermore, the mosquito in works of poetry and fantasy also shows the interconnection of medical, political, and environmental issues. This chapter briefly examines Ronald Ross’s pamphlet ‘Mosquito Brigades and How to Organise Them’, in order to understand the main tenets of the colonial myth of malaria eradication: environmental intervention, exploitation of and scepticism towards local populations as ‘carriers’ of malaria, and racial separatism. We then turn to Indian nationalist reinscriptions of malaria prevention in Rabindranāth Tagore’s speech to the Anti-Malaria Society. Tagore stresses community engagement and questions the widespread health impacts of British ‘development’ projects. Finally, we examine how fiction and poetry by Trailokyanāth Mukhopādhyāy, Rabindranāth Tagore, and Annadāshankar Ray introduce elements of the fantastical, especially around questions of scale, to question the quantification and control of malaria. We suggest that these poetic and fantastical works point towards the artificiality of Western concepts of literary realism themselves.
The War with the Mosquito: Ross and Tagore In the colonies, hygiene measures to control malaria were based on racist illness geographies, which labelled swaths of Africa and India as unhealthy. After the discoveries in that malaria was transmitted
development’. Rohan Deb Roy, Malarial Subjects: Empire, Medicine and Nonhumans in British India, –, Science in History (Cambridge: Cambridge University Press, ), p. . Using the word ‘fantastical’ rather than terminology such as ‘magical realism’ to analyse the poetry and short fiction decentres assumptions about the development of realism versus the fantastical that are influenced by the Western canon. In the works under consideration, these are intertwined. In the introduction to Undisciplining Victorian Studies, Ronjaunee Chatterjee, Alicia Mireles Christoff, and Amy R. Wong remind us of Elaine Freedgood’s argument in Worlds Enough () that ‘“aesthetic racism” underlies the invention of British (and French) realism, which is still imagined as the coherent, formal point of arrival or departure for non-Western novels’. Ronjaunee Chatterjee, Alicia Mireles Christoff, and Amy R. Wong, ‘Introduction: Undisciplining Victorian Studies’, Victorian Studies, , (), – (p. ). As Dipesh Chakrabarty observes in Provincializing Europe, the ‘idea of the subject’, ‘scientific rationality, and so on’ all ‘bear the burden of European thought and history’, creating a ‘universal and secular vision of the [white, European] human’. Dipesh Chakrabarty, Provincializing Europe: Postcolonial Thought and Historical Difference (Princeton: Princeton University Press, ), p. . Jessica Howell, Exploring Victorian Travel Literature: Disease, Race and Climate, Edinburgh Critical Studies in Victorian Culture (Edinburgh: Edinburgh University Press, ); Mark Harrison, Climates & Constitutions: Health, Race, Environment and British Imperialism in India, – (Delhi and Oxford: Oxford University Press, ); David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India (Berkeley: University of California
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by the Anopheles mosquito, these illness geographies were incorporated with measures to kill mosquitoes. By , imperial scientist Ronald Ross felt that the British government still had not done enough to eradicate malaria based on recent scientific knowledge. He sought to train and deploy anti-malaria vigilantes who would start ‘mosquito brigades’ in the colonies of highest white mortality, supervising the overhaul of local habitats and environments in order to wipe out mosquito populations. In his pamphlet ‘Mosquito Brigades and How to Organise Them’, Ross suggests that large bodies of water should be covered with crude oil, and drinking water covered with a film of kerosene or eucalyptus oil. Ross himself tried such measures in Sierra Leone, with limited success. His ambition to extirpate mosquitoes had notable literary after-effects. In declaring ‘war’ on the mosquito, Ross also advocated forms of biopower and surveillance that treated local populations as primarily valuable for hard labour and as possible disease carriers to be treated with suspicion. As Emilie Taylor-Pirie notes, Ross’s methods were acknowledged as unsuccessful and unsustainable: his plan was ‘rejected by district boards and municipal councils in the Madras Presidency in India owing to resistance from local health officials and concerns about cost’. Part of the resistance may have been to the exploitative nature of these interventions. For example, in the African context, Ross claims that villagers undo any progress due to their ‘fondness for digging holes’, and advocates using one’s own African porter as a tool to measure mosquito populations by letting him sleep under a torn net. As scholars of literature and medicine, health humanities, and postcolonial studies have shown, the struggle to control malaria and survive malarial illness captured the imagination of Anglo-European writers of the nineteenth and twentieth centuries, who creatively reinterpreted disease discourse within their works of fiction.
Press, ); David L. Livingstone, ‘Climate’s Moral Economy: Science, Race and Place on PostDarwinian British and American Geography’, in Geography and Empire, ed. by Anne Godlewska and Neil Smith (Oxford: Blackwell, ), pp. –. Deb Roy, p. . For more on how the rhetoric of war has been used to bolter nationalist and colonialist medical campaigns, see Lorenzo Servitje, Medicine Is War: The Martial Metaphor in Victorian Literature and Culture (Albany: State University of New York Press, ); Emilie Taylor-Pirie, Empire under the Microscope: Parasitology and the British Literary Imagination, – (London: Palgrave, ), especially Chapter : ‘Microbial Empires: Active Transmission Strategies and Postcolonial Critique’ (pp. –). Taylor-Pirie, p. . ‘Western’ literature of the late nineteenth and early twentieth centuries that engages malaria includes fiction by Charles Dickens, Henry James, Arthur Conan Doyle, Thomas Hardy, Bram Stoker, as well as imperial adventure fiction by H. Rider Haggard and his contemporaries.
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Malaria Literature
Debates about the mosquito in Bengali cultural circles highlight the hubris of Ross’s suggested interventions. When Rabindranāth Tagore spoke to the Anti-Malaria Society in August , he drew upon similar rhetoric as Ross, by calling for a ‘war with malaria’. However, in a speech to the same society in February , this Nobel Laureate and ‘apotheosised’ ‘national poet of India’ instead advised that malaria eradication be controlled by local communities as an act of independent nation-building. The belief that malaria prevented development was the same, but Tagore argued that the benefits should be for the people of India, not the colonizer. Malaria as a ‘category’ occupied ‘the centre stage in vernacular imagination as a crucial node of anti-colonial resistance and nationalist reconstruction, percolating into the arena of provincial print cultures’. In his speech, Rabindranāth stresses the limitation of human agency, when he says: ‘Fortifying ourselves from all sides and not letting malaria enter, eradicating it completely – this is not in our hands.’ In fact, there is an implied critique of an individualistic, medicalized solution: ‘No one person can say, “I will eradicate all the malaria and kālā āzar in the land with quinine and injections.”’ Rather than focusing purely on the physical threat of malaria to an inviolate self, he portrays the human subject as an interdependent whole: ‘a human cannot be divided – a person is a mix of body, mind, and soul’. He recommends community action to provide clean water and as a form of independence from Britain: ‘From our sense of aesthetics, to our ideas of earning, agriculture, cultivation, in all realms our country needs to be independent.’ This goal was a tenet of the early-twentieth-century Indian independence movement.
Twentieth-century works that engage malaria include Karen Blixen’s Out of Africa () and E. M. Forster’s A Passage to India (), among others. The main symptom of ‘fever’ was often used to indicate malarial illness in such works. See Christopher Hamlin, More Than Hot: A Short History of Fever, Johns Hopkins Biographies of Disease (Baltimore: Johns Hopkins University Press, ). Authors variously used malaria to engage decadence and degeneration, the spectre of colonial failure, narrative introspection, chronic illness and sensory changes, and nationalist and racist illness geographies. Postcolonial authors respond to and subvert some of the foregoing colonialist tropes of containment and cure within their works, as in Amitav Ghosh’s Calcutta Chromosome (). For more analysis of malaria in literature, see Jessica Howell, Malaria and Victorian Fictions of Empire (Cambridge: Cambridge University Press, ); Alvan A. Ikoku, ‘Reading Malaria Literature’, Literature and Medicine, , (), –; Bassam Sidiki, ‘Parasitic Empires: Immunity, Insularity, Inter-Imperiality, –’ (unpublished doctoral thesis, University of Michigan, ); Taylor-Pirie. Deb Roy, p. . Deb Roy, p. . Deb Roy, p. . Rabindranāth Tagore, ‘Malaria’ (Lecture presented at the Anti-Malaria Society), Rabindra Rachanābali Vol (Kolkata: Visva Bhārati, ), p. –. Translated by Oishani Sengupta. Tagore, Rabindra Rachanabali, p. . Tagore, Rabindra Rachanabali, p. . Tagore, Rabindra Rachanabali, p. .
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Late-nineteenth-century social reformers focused on the city as a locus of overcrowding and disease. As Projit Mukharji notes, a ‘new generation, . . . following the conspicuous examples of men like Rabindranāth, came to position the village as a site for patriotic activity (grām-samskār)’. Subsequently, the ‘clearing of village ponds of water hyacinths (pānā), levelling of village roads by filling ditches and removing of scrub around the villages’ were acts undertaken by ‘numerous patriotic youth’. These environmental interventions were undertaken with the understanding that the same measures of development previously introduced by Britain, such as the indiscriminate building of roads and railways, had in fact exacerbated the malarial burden in India. Rabindranāth states, ‘it is a great truth, malaria has reached those parts of our country where it did not previously occur. The reason is, our country did not have the railways, and there was no barrier preventing the natural flow of water.’ He acknowledges the human suffering caused by this development, and that anger might be the result: it is understandable to want ‘cry out in unison, “We will break your railway lines. What makes you think you can profit when we’re dying?”’ Rabindranāth instead attempts to catalyse dedication to internally driven development projects. Rabindranāth’s speeches critique the Anthropocentric interventions of colonial governments, which attempted to control disease by controlling the environment. His assertion that ‘a human cannot be divided’ stresses holism, not only asserting that the body cannot be separated from the mind or soul, but also that it cannot be separated from its environment. Within his work, as well within as the examples that follow, one sees an important predecessor to contemporary connections between the environmental and the medical/ health humanities. Variously called planetary health humanities, medical posthumanities, or health and medical geographies and the humanities, these current initiatives acknowledge the interdependence of human with environmental and non-human health. In a recent article in GeoHumanities, the co-authors advocate extending ‘medical-health humanities into more-
Mukharji, Nationalizing the Body, p. . Mukharji, Nationalizing the Body, p. . Tagore, Rabindra Rachanabali, p. . Tagore, Rabindra Rachanabali, p. . Bradley Lewis, ‘Planetary Health Humanities – Responding to COVID Times’, The Journal of Medical Humanities, , (), –. Baldy Center for Law and Social Policy University of Buffalo, ‘Medical Posthumanities: Governing Health Beyond the Human’ [accessed October ]. Sarah de Leeuw and others, ‘Geographies of Medical and Health Humanities: A Cross-Disciplinary Conversation’, GeoHumanities, , (), –.
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Malaria Literature
than-human geographies’. Indigenist health humanities scholars might argue this is not a novel approach, but one long encompassed by indigenous knowledge practices. For example, Chelsea Watego and her co-authors advocate for understanding people ‘in their full, relational sense rather than as atomistic, potential loci of pathology’. They echo Rabindranāth’s argument from a hundred years earlier that colonialism and its legacies are central to the social, geographical, and political determinants of health.
The Morphic Mosquito: Trailokyanāth Mukhopādhyāy Plays with Scale While social and medical discourses of improvement often portrayed the mosquito as an enemy to be conquered, Bengali imaginative literature had a long-standing tradition of undermining this trope. Trailokyanāth Mukhopādhyāy (–), also known in his English-language works as T. N. Mukherjee, was a leading figure of the Bengal Renaissance. The Bengal Renaissance was a period of sociopolitical transformation in eighteenth- and nineteenth-century Bengal which affected every facet of cultural life. Reacting to colonialism, Bengali intellectuals interrogated and reshaped social practices, customs, religious observances, literature, art, music, and dance, in response to the widespread impact of British colonialism. It is commonly held that this period is bookended by the two influential figures, the social reformer Rājā Rāmmohan Roy, and the poet and scholar Rābindranāth Tagore. As well as writing history books and fiction, Trailokyanāth was the author of the widely read travelogue A Visit to Europe (). He used satire to critique both the hubris of colonial education and the assumptions and practices of the Bengali middle class. Damaru-charit, or Tales of Damaru, published posthumously in but likely composed much earlier, is a collection of satirical sketches that use grotesque depictions of late colonial India.
de Leeuw and others, p. . Chelsea Watego and others, ‘Black to the Future: Making the Case for Indigenist Health Humanities’, International Journal of Environmental Research and Public Health, , (), (p. ). In Malarial Subjects, Rohan Deb Roy observes that ‘the deeply layered world of literary production, for instance in Bengali, featured mosquitoes as ubiquitous objects of fun, satire and irritation . . . Painful, irritating yet funny encounters between human skin and mosquitoes’ stings remained an enduring theme in a range of fables, fantasies and poetry’ (p. ). An important text that documents the cultural milieu of the Bengal Renaissance is Sibnath Sastri, Ramtanu Lahiri, Brahman and Reformer: A History of the Renaissance in Bengal, trans. by Sir Roper Lethbridge (London: Swan Sonnenschein & Co, ).
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In the tale ‘The Strange Creature of Sunderban’, characters Damarudhar and Lambodar are discussing the unusual appearance and behaviour of mosquitoes in the Sundarbans, an area of mangrove forests located in the southernmost parts of West Bengal in India and southwestern Bangladesh. Trailokyanāth uses fantastical description, especially of scale, to satirize the fatalism associated with mosquitoes. He changes the symbolism of the mosquito, yoking it not only to death and destruction but also to generative linguistic, conceptual, and physical properties. He also mocks the geographical stereotypes, formed by both middle-class Bengali prejudice and by ‘biased imperial settlement reports’, which characterized the Sundarban region as an area defined by ‘the struggle between man and beast’ (sometimes tigers, but often mosquitoes). Finally, the tale lampoons the colonial education system, and specifically the syllogisms that underpin colonial logic, to show that Western rationality is as fantastical as any superstition. Damaru begins his tale by saying that he hired six boatmen and a sain, or holy man who can ward off tigers, to ‘find out how to cultivate’ a farm that had been sold to him at an extreme discount. Through the course of the story, he discovers why the land was so inexpensive. The boat approaches a farm that has been reclaimed by the mangroves and by water: ‘some of the land was covered by forests’ and there were places where ‘the dyke was broken’, allowing salt water to re-enter. Approaching the last farmer’s cottage left standing, Damaru and his companions see a dead tiger outside and hear a buzzing noise like ‘the humming of millions of bees’ within. These foreboding sensory descriptions set the stage for their shocking discovery: What we saw in the next instant completely bewildered me. Hundreds of strange black creatures like sparrows were perched on the wall. Their entire body was black but the underside was red. They had a pair of wings which they were flapping in order to fly. . . . What creature was this? I could not understand at all.
Three or four of the creatures attack the sain, who screams ‘I’m dying, I’m dying’ and falls to the ground convulsing after ‘advancing ten paces’. After the creatures also attack and kill a boatman, Damaru concludes they
Sutapa Chatterjee, The Sundarbans: Folk Deities, Monsters and Mortals (New York and London: Routledge, ), p. . Sutapa Chatterjee, p. . Trailokyanāth Mukhopādhyāy, “Damaru Charit” [Tales of Damaru], Trailokyanāth Rachanābali (Kolkata: Pātra’s Publication, ), p. –. Translated by Oishani Sengupta. Mukhopādhyāy, p. . Mukhopādhyāy, p. . Mukhopādhyāy, p. .
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transmit ‘a deadly poison’ and drink blood. He picks up a carcass of one of the dead animals before escaping. When he has time to observe the animal more completely, he is ‘astounded’ to find that they were nothing other than large mosquitoes. Mosquitoes as big as sparrows. I had never heard that mosquitoes could be so big. The body was as big as a sparrow, the trunk as big as a large leech. There was a sharp edge in front of its trunk like the knives doctors use to cut and open boils. They settle on the body of animals or people and first cut out some of the skin and flesh. Then they insert their trunk and suck out the blood. They not only kill animals by sucking out the blood, but by their deadly poison which causes animals to convulse and die.
Undeterred, Damaru returns with several servants and sets about trapping the huge mosquitoes in nets. He says the first day they trapped ‘two thousand mosquitoes, the day after sixteen hundred, then twelve hundred and in this way the number of mosquitoes declined. In thirty-five days the mosquitoes were completely wiped out.’ Though he is the son of a lower-middle-class family who has worked as an assistant to a cloth merchant, Damaru here demonstrates the ambition to become a settler-farmer. However, through his battle with the fantastical mosquito-beasts, the story invokes both the hubris of colonial medicine, as well as the illogic of colonial education. Malarial eradication is here exaggerated as the capture of thousands upon thousands of bird-sized, deathly mosquitoes, until they are gone. The mere physical impossibility of such a task crystallizes the underlying impossibility of eradicating small, invisible mosquitoes as well. Further, Damaru depends on a series of similes to make sense of something new to him, which he initially ‘could not understand at all’, implying that mosquitoes, and the poison that they carry, defy full comprehension. They are ‘like’ sparrows (the word sparrow appears three times), their trunks (here used to indicate proboscises) ‘as big as’ leeches with sharp edges ‘like’ knives. The slippage of signification also associates them with other bloodsucking and flying animals that are seemingly unrelated to the mosquito. The naysayer of the tale, Lambodar, questions Damaru’s logic. Their other friend, Shankar Ghosh, answers Lambodar’s doubts with empty logical syllogisms that undermine the value of a colonial education. When Lambodar says: ‘I do not believe mosquitoes can be so large’,
Mukhopādhyāy, p. .
Mukhopādhyāy, p. .
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Shankar Ghosh answers: ‘Elephants are nothing but large mosquitoes. Mosquitoes have trunks, so have elephants.’ Damaru says he dropped the trunk in a pool of water, and it grew leeches. When Lambodar says: ‘Leeches cannot grow from mosquito trunks’, Shankar Ghosh says: Someone with a BA or MA or some other degree wrote a school level text on farming in Bengali. There he wrote the following about the mint plant – cover a piece of rope with jaggery and hang it outside. Flies will sit on it attracted by the jaggery and defecate on it. When the rope is full of the urine and excreta of the flies then bury it in the ground. From this the mint plant will be born. If the excreta of flies can produce the mint plant, why cannot leeches grow from mosquito trunks?
The necessity of a BA or MA degree to develop this convoluted farming practice emphasizes the invisible line between superstition and educational logics. In addition to being fatal, in this story the figure of the mosquito is also productive and generative: Damaru says that, not only do their torsos look like leeches, but the mosquitoes actually grow leeches from their ‘trunks’, when submerged in water. He tells his listeners: ‘I cut off the trunk of the mosquito and threw it in the pool near our village. Many large leeches have grown from that trunk. If you don’t believe me get inside that pool.’ He also narrates that his servants discarded the appendages and roasted the bodies of the mosquitoes, which tasted ‘like bats’. Thus, the mosquito creates and supports new life, and takes life away, functioning as part of a human–non-human ecology. Finally, the process of reading Trailokyanāth’s work in itself can cause a self-reflective questioning of the ‘inexorable and relentless symmetry of things’. A previous translator of his work, Arnab Bhattacharya, notes that reading Trailokyanāth’s fiction taught him to ‘break free of the siege mentality’ that demands a fixed sense of scale.
s Poetry: The Mosquito and Self-Reflection Trailokyanāth’s satire of what one might call ‘mosquito horror’ in the foregoing story depends on his literary experimentation with scale. Ronald Ross and his contemporaries were intimidated by malaria’s mobility owing to the tininess of mosquitoes, which makes them difficult to perceive: in
Mukhopādhyāy, p. . Mukhopādhyāy, pp. –. Mukhopādhyāy, p. . Mukhopādhyāy, p. . Trailokyanāth Mukhopādhyāy, Domoruchorit: Stunning Tales from Bengali Adda, trans. by Arnab Bhattacharya (Oxford: Oxford University Press, ), p. xvi.
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‘Mosquito Brigades’, Ross says that ‘whatever efforts . . . we may make, we cannot, especially in the tropics, entirely avoid being bitten’. Being able to see the mosquitoes of Damaru’s world, figuratively speaking, from a mile away, makes the ‘real’ turn-of-the-century obsession with pinpointing and containing them seem absurd. When referring to these works’ experimentation with scale, we assume that scale relates to observational thresholds, and not to physical distance. In Scale Theory: A Nondisciplinary Inquiry (), Joshua DiCaglio says, ‘the change in the relative position of observer and observed leads to an alteration in what is able to be distinguished as an object’. This position is what he calls a ‘threshold’: the change in ‘kind and quality of information that can be perceived as one alters the scale of observation’. One may use technologies of viewing to move ‘beyond the perceptual limits of the human body’. Further, one also may arguably use aesthetic and literary ‘viewpoints’ to change the threshold of observation. DiCaglio argues that: ‘Scaling smaller reveals multiplicity (more units within a unit), scaling larger reveals unity (a unit that encompasses given units).’ In addition, ‘both ends of the scale are equivalent’ – an experience that DiCaglio relates to the Bhagavad Gita’s concept of ‘kūtastham, the unchanging, or “that which stands at the top or the highest _position”’. We tend to privilege a given scale – a process that DiCaglio calls scalism. This sense of proportion is the foundation for our ‘sense of reality, language, and culture’. Scalism also encourages us to assume that certain scales, such as the microscopic or the cosmic, ‘hold more explanatory power’ than any other, often when they are ‘newly’ discovered by science and technology. This obscures the ‘underlying questions about the ambiguities and limits of scientific description’. If we define reality upon a shared sense of scale, then, as this chapter has suggested, using ‘realism’ to describe literary texts is arguably limited due to its dependence upon Western assumptions about perceptibility. That is, portraying the body and its relationship to space is only as valid as the shared cultural scale of embodiment and identity that frames that relationship.
Ronald Ross, Mosquito Brigades and How to Organise Them (London: George Philip & Son, ), p. . Joshua DiCaglio, Scale Theory: A Nondisciplinary Inquiry (Minneapolis: University of Minnesota Press, ), p. . DiCaglio, p. . DiCaglio, p. . DiCaglio, p. . DiCaglio, p. . DiCaglio, p. . DiCaglio, p. . DiCaglio, p. .
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In the following s poems by Annadāshankar Ray and Rabindranāth Tagore, both authors use poetic ‘vision’ to shift their readers’ understanding of the scale of human–mosquito relationships. Dipesh Chakrabarty’s concept of the ‘dissolving shot’ is helpful here: in discussing Rabindranāth’s poem Bansi (‘The Flute’), Chakrabarty notes a shift in ‘mood’ and ‘register’. He says that midway through the poem, Tagore ‘executes something like what the language of film might call a dissolving shot, one that replaces one frame with another and challenges our vision. The poem mounts nothing short of a full-scale attack on the historical and the objective.’ In the following poems, the repeated inversion and ‘dissolving’ of scale between population and individual, individual and mosquito causes the reader to question the value system inherent in distinguishing between human and non-human worlds, friend and enemy, self and other. Further, the multiscalar idea of the mosquito is reflected in the complexity of Bengali as a language. Cultivated by Rabindranāth and others as both an aesthetic and a communicative medium, this ‘living language’ bridges the meanings of Sanskrit and common-speak. Thus, creativity and flexibility are inherent in the form of expression. Gandhian in politics, Annadāshankar Ray was inspired by Rabindranāth Tagore. He was a bitter opponent of the partition of and wrote several Bengali poems criticizing it. Rohan Deb Roy translates the following poem’s title, ‘Kanduni’, as ‘In Tears’. Depending on context, the word can also mean whining, or a repeated complaint. Therefore, what is layered within the title itself is the sensory experience of being trapped with a mosquito, hearing its whine, and needing and wanting to escape. The original translation of ‘in tears’, or ‘tearful lament’, captures the speaker’s sense of being forced to flee by mosquitoes. However, once again, the layering of political and historical references changes the scale of impact: the mosquito affects the nation, the town, and the individual, all at once. The poem also undermines the connections between disease and racial and national superiority advocated by British colonialism, whereby the virtuous or superior subject remains well. Everyone – the enemy forces of Japan, the East Indian Company, and the speaker, whom the reader assumes is Bengali – is forced to flee the ‘Mosquitoes of Kesh’nagar’. There can be no instrumentalizing mosquitoes in the cause of nation-building, because they are agents without loyalty. The poem reads,
Chakrabarty, p. .
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Not tigers, not bears Nor the Japanese Not bombs, not cannons But a shaking in my spleen Mosquitoes Tiny mosquitos! ... Legends say mosquitoes Can be fought With nets The Fifth column Lets them in Through the gates. I wage the war alone With this hand and that On the tip of my nose Both land with a whack How do I avoid My own whack And their sting! ... O Moshāi Mosquitoes of Kesh’nagar forced me to flee!
As in Rabindranāth Tagore’s poem which follows, a dominant image is the mosquito sitting on the tip of the speaker’s nose. To attack the mosquito would be to hurt one’s own face, to be momentarily blinded by one’s own hand. Not only that, but it is almost physically impossible to look closely at something at the tip of one’s own nose; this would mean straining the eyes to shift one’s own vision to the almost imperceptible. To be ‘nose to nose’ or ‘face to face’ with a mosquito implies a kind of intimacy that is different to the distance of crushing an insect on one’s forearm, or swatting it with a rolled-up newspaper on the wall. The ‘Fifth column’ implies that the ‘war’ against a mosquito will always have an unprotected flank, so to speak, by which the bite can enter. Finally, when the speaker says ‘In the end / Malaria / Caught a hold of me’, he shows that
Annadāshankar Ray, ‘Kaduni’, in Adhunik Bangla Kabita, ed. by Buddhadeb Basu (Calcutta: M. C. Sarkar and Sons Private Limited, /), pp. –. Translated by Oishani Sengupta.
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illness is more potent than all the human and animal forces listed above (tigers, bears, bombs, the Japanese). Both Annadāshankar’s ‘Kānduni’ and Rabindranāth Tagore’s ‘Ode to a Mosquito’, or ‘Moshokmongolgitikā’, contain a direct address to the insect. Rabindranāth draws on the poetic genre of the ode and on metaphysical poetry while creating formal innovation in scale and perspective. Given the documented influence of John Donne’s work on his own, it could well be that the humour of John Donne’s ‘The Flea’ () influenced ‘Ode to a Mosquito’. In addition, Rabindranāth’s formal experimentation is distinctive in the slippage between human and non-human perspectives, and his mixture of melancholy with humour. The melancholy in both ‘Kānduni’ and ‘Ode to a Mosquito’ perhaps relates not only to the inevitable presence of mosquitoes, but also to the historical context of the upheaval of s India. Rabindranāth’s speaker calls the mosquito ‘[s]lighter than a blade of grass, sturdier than a tree’. As in Damaru-charit, the mosquito is defined not by what it is, scientifically, or by what it carries, but by the properties that relate it to other animals and plants. Further, the poem’s speaker wonders what he may learn by imaginatively becoming a mosquito, being so ‘poor’ and ‘frail’ but also confident and calm: ‘Very quiet, unconcerned I sit / Perched silently on the tip of my devotee’s nose.’ From these lines, the reader understands that becoming a mosquito is the ultimate lesson for the speaker, to reach ‘the final state of poverty’. Poverty may here mean a kind of a spiritual detachment from materiality. The poem ends with the mosquito flying away on the sound of a chant: What has happened to me! The sweet mosquito flute’s suddenly quiet. I flap my wings, There isn’t the slightest buzzing – Except ‘Ram, Ram’ sliding off my wings, Such is the state of my poverty.
The poem’s perspective shifts from the speaker’s ‘I’ to the mosquito and back again, emphasizing their oneness. ‘Me’ in the first line becomes ‘the mosquito’ in the second, and then ‘I’ again, and ‘my wings’. There is no looking at, or
For the influence of Donne on Tagore’s work, see Kalyan Chatterjee, ‘Cross-Cultural Transactions: Rabindranath Tagore, John Donne, and Peter Damian’, ANQ: A Quarterly Journal of Short Articles, Notes and Reviews, , (), –. Rabindranāth Tagore, ‘Moshokmongolgitikā [Ode to a Mosquito]’, in Prohāshini (Kolkata: Visva Bhārati, ), p. . Tagore, ‘Moshokmongolgitikā’, p. . Tagore, ‘Moshokmongolgitikā’, p. .
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looking through, but both at once. Therefore, in this section, Rabindranāth’s speaker moves even closer to the insect than merely addressing it. The speaker becomes the insect, fundamentally challenging a medical perspective that advocates Anthropocene, human interventions. To swat the mosquito is now to risk not only harming one’s face but killing the self entirely.
Conclusion Inhabiting a range of literary and cultural contexts through persistent cultural tropes, the mosquito emerges as a site of discursive exchange between colonial and anti-colonial writing in Bengal. Poems, novels, and public lectures all share these significant figurations – of the mosquito as infinitesimal yet omnipotent, invisible yet deeply painful, fleeting yet destructive at a global scale. By engaging the imaginative reinterpretations and subversions of antimosquito warfare in fiction and poetry, our analysis of select examples of late-nineteenth- through mid-twentieth-century Bengali literature demonstrates the conceptual mobility of disease within different literary cultural traditions. As is evident from the foregoing excerpts of works by Trailokyanāth Mukhopādhyāy, Annadāshankar Ray, and Rabindranāth Tagore, each author portrays the mosquito very differently. However, each also uses sequences of shifting scale to understand the mosquito, and thus malaria, as defying quantification. In Damaru-charit, the mosquito is simultaneously a figure of horror, satire, and anti-logic simultaneously; in Kanduni, mosquitoes have impact on both the national and individual level. They are figures of annoyance as well as historical import. ‘Ode to a Mosquito’ encourages us to use the mosquito to think through what is transient and what is timeless, and to question our separation from the non-human world. The dual authorship of this chapter is part of its methodology. All translations are original, by Oishani Sengupta, who also provided biographical and contextual information for each author’s work. The coauthors discussed the meanings of specific words and images as multivalent and contextually dependent. The extracts of the Bengali works that we have selected manifest this changeability, and so invite a self-reflective and creative translation practice. This plasticity is not only conceptual but material – some of the texts were presented as speeches, while others first appeared in reputed literary periodicals. In many cases, their republication in collected volumes or as single novels erases some aspects of how readers would have perceived them at the time. While we are able to gesture towards some of the trajectories of production and publication of the texts
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we have selected, critical details remain obscured from the cultural record. Unfortunately, such gaps are characteristic of the difficulties of locating specific information on Bengali print culture of the nineteenth and twentieth centuries. We also acknowledge that each of these works deserves sustained scholarship in its own right. By specifically focusing on representations of mosquitoes and malaria within them, we hope to encourage further in-depth engagement within literature and medicine studies on the politics and aesthetics of embodied social conditions of infection and infectivity within colonial and postcolonial literature from India. More than responding to or reinterpreting colonial medical value systems within their work, these writers use literary techniques to develop original connotations of malaria that draw upon understandings of interdependence and interrelationship. Their experimentation with scalar variation encourages readers to revise our understanding of the conventions of literary realism as based in Western assumptions about perception. These authors prove that the concept of realism is fantastical. Trailokyanāth illuminates colonial and racist medical geographies by satirizing both the stereotypes of unhealthy ‘jungle’ areas like the Sudarabans and the delusion of ‘warring’ with mosquitoes. Rabindranāth and Annadāshankar show the futility of top-down anthropocentric interventions that promise to eradicate mosquitoes. Their poetry further represents the human subject as entangled with the proliferation and eradication of malaria. They use the mosquito as an optic to dissolve the boundaries of an inviolate self. Often, contemporary scholarship of illness narrative has assumed that infectious disease is an unwelcome incursion by an external vector or agent against a boundaried self, defined either by its immunity or vulnerability. Critical medical humanities scholars such as Rosemary Jolly suggest that the COVID- pandemic spur us to redefine zoonotic (and parasitic) disease as ‘reverse zoonoses or zooanthroponoses (passing from human to non-human animals) at the systemic level’. Jolly argues that acknowledging the interdependence of human and non-human health is part of a decolonial, non-anthropocentric approach. The late nineteenth- and twentieth-century Bengali authors whose work we have analysed within this chapter anticipate this interrelationship by immersing the reader in the experience of encountering the mosquito.
Rosemary J. Jolly, ‘Decolonising “Man”, Resituating Pandemic: An Intervention in the Pathogenesis of Colonial Capitalism’, Medical Humanities, , (), – (p. ). Jolly, p. .
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Forgotten Class French Literature, Medicine, and Poverty Loïc Bourdeau
It is perhaps axiomatic to bring together French literature, medicine, and poverty. These terms operate quite seamlessly and intimately in French cultural productions. From Molière’s Le Malade imaginaire (The Imaginary Invalid) (), Honoré de Balzac’s Le Médecin de campagne (The Country Doctor) (), or Hervé Guibert’s Cytomégalovirus. Journal d’une hospitalisation (Cytomegalovirus. A Hospitalisation Diary) () to more recent productions like Maylis de Karengal’s Réparer les vivants (The Heart) () and Philippe Lançon’s Le Lambeau (Disturbance) (), disease and medicine have indeed long populated France’s literary imaginary. Poverty, too, has inspired classics such as Victor Hugo’s Les Misérables () or Émile Zola’s Germinal (). Yet, to appose literature, medicine, and poverty also sheds light on the fraught relationship between these three terms. Fraught insofar as working-class individuals or individuals experiencing poverty have, on the one hand, limited access to the cultural capital necessary to being a published French author, and on the other, a complicated relationship with healthcare systems and providers. The ongoing COVID- pandemic has further illustrated the ways in which disease continues to inspire cultural actors, while drawing attention to heightened social, political, cultural, and medical inequalities. The proliferation of films ( rue de l’Humanité [Stuck Together], ), television series
See, for instance, Steven Wilson, The Language of Disease: Writing Syphilis in Nineteenth-Century France (Oxford: Legenda, ). Wilson’s study explores the representation of the diseased body as well as the relationship between language, literature, and illness. Most, if not all, of the cited authors had or have a privileged social status. Further, I speak here not of self-publishing or new, more democratic forms of publishing (which still require some cultural capital). Rather, I refer to France’s publishers, institutions, and cultural actors who allow a writer to become an author. As Clea Chakraverty remarks in her Slate article, while ‘more than half of the French population age + have written or would like to write something’, the title of author is not for everyone. It carries an aura and refers only to the highest rank of the ‘intellectual aristocracy’. Clea Chakraverty, ‘Il y a trop de gens qui écrivent des livres’, Slate, November [accessed June ].
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(Plan Coeur [The Hook Up Plan], –), books (Sylvie Germain’s Brève de solitude, ) and online diaries (by Leïla Slimani, Marie Darrieussecq, or Wajdi Mouawad, ) attests to the power of culture to respond to crises in quick and effective ways. It bears noting that these creative responses have for the most part offered bourgeois accounts of the pandemic. During lockdown, in countries such as France, the United Kingdom, or Singapore, people joined weekly initiatives to clap for healthcare professionals, as well as other frontline workers and carers, especially ‘cleaners, cashiers, delivery drivers’. The voices of these individuals, however, remained overall absent from the media and artistic productions. Despite this invisibility when it comes to the voices from the pandemic, twenty-first-century French literature has demonstrated a growing interest in the working class. This is partly thanks to established figures such as Nicolas Mathieu, winner of the Prix Goncourt, France’s most prestigious literary prize, or feminist Virginie Despentes as well as the fact that ‘the social novel is no longer only written by established bourgeois figures . . . but also by men and women who . . . have experienced class contempt, financial problems or even injustices’. Alexandre Gefen, among others, shows that contemporary productions are indeed widely concerned with vulnerable and marginalized individuals and identities and try to counter suffering through writing and care. French writer Édouard Louis perhaps best epitomizes this phenomenon of a caring literature, that is ‘a literature that cures, that heals, that helps, or, at least, that “makes you feel good”’. In Louis’s case, more specifically, it is a politically minded literature that makes ‘“visible” the destiny of fragile individuals in a world full of challenges’; it is a literature that ‘invites our attention, thereby beckoning us to invest emotionally or intellectually in a relationship that embodies the very dynamic of care’. Born in , Louis grew up in the poverty-stricken and far-right-leaning village of
Najat Vallaud-Belkacem and Saudra Laugier, La Société des vulnérables: Leçons féministes d’une crise (Paris: Gallimard, ), p. . Unless otherwise indicated, all translations from French to English are my own. Tara Lennart, ‘Pourquoi les classes populaires fascinent-elles les écrivains?’, Magazine Antidote, March [accessed June ]. See also, Loïc Bourdeau, Natalie Edwards, and Steven Wilson, ‘The Care (Re)Turn in French and Francophone Studies’, Australian Journal of French Studies, , (), –; Kathryn Robson, I Suffer, Therefore I Am: Engaging with Empathy in Contemporary French Women’s Writing (Oxford: Legenda, ); Sandra Laugier, Politics of the Ordinary: Care, Ethics, and Forms of Life (Leuven: Peeters, ). Alexandre Gefen, Réparer le monde: La littérature française face au XXIe siècle (Paris: Corti, ). Gefen, p. . Bourdeau, Edwards, and Wilson, p. .
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Hallencourt, in the North of France. In addition to the difficult living conditions, Louis experienced the violence of homophobia, which he recounts in his first critically acclaimed novel En finir avec Eddy Bellegueule (The End of Eddy) (). A class defector who became close friends with intellectuals Didier Éribon and Geoffroy de Lagasnerie, Louis has been using his artistic practice to call out political leaders whose reforms primarily affect the poor and to give a voice to these individuals who experience multiple forms of violence daily. I have shown elsewhere how Louis’s ‘writing about bodies, the working-class milieu, hegemonic masculinity makes visible individual and collective domination’; yet the many references to and encounters with healthcare institutions and providers throughout his oeuvre remain largely unexplored. For this study, I look primarily at his debut novel mentioned above as well as Qui a tué mon père (Who Killed My Father) (), Changer: Méthode (Change: Method) (), Combat et Métamorphoses d’une femme (Battles and Metamorphoses of a Woman) (), and his conversational essay with British filmmaker Ken Loach, Dialogue sur l’art et la politique (Dialogue on Art and Politics) (). This chapter seeks to analyse the relationship between (white) working-class/poor individuals and medicine, masculinity, and care. In particular, I shed light on Louis’s strategy to deploy a ‘democracy of care’, that is, a type of social organization grounded in equality, more horizontal relations, and which values care (and care workers) over economic production. As this volume investigates the reciprocal relation of literature and medicine, it does not only appear that Louis’s writing about pain serves to reflect on France’s healthcare policies and inequalities, but also that power dynamics (such as patient–doctor) inform his writing practice.
Loïc Bourdeau, ‘De “Pas comme les autres” à “tous dominés” dans En finir avec Eddy Bellegueule d’Édouard Louis’, Nouvelles Études Francophones, , (), –. For this analysis, I use the official English translation of The End of Eddy; I have translated quotes from his other books except Who Killed My Father. I refer to the French text but use Lori Stein’s official translation from an EPUB version (no page numbers). I draw this definition from Joan C. Tronto’s Caring Democracy: Market, Equality, and Justice (New York: NYU Press, ), p. . The French context of the past ten years or so has been a fruitful ground for care ethics. Fabienne Brugère, Marie Garrau, and Sandra Laugier, to name a few, have indeed drawn much attention to the field and engaged with the work of Carol Gilligan and Joan C. Tronto. As I do here, care has always been understood and deployed as a moral, philosophical, and political concept that offers alternative models of sociality, relationality, and community. Our special issue of the Australian Journal of French Studies likewise attests to the renewed interest in analysing cultural productions through the lens of care. See Bourdeau, Edwards, and Wilson.
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Paging the Country Doctor In his contribution to The Cambridge History of Medicine, Edward Shorter provides an overview of the evolving relationship between primary caregivers (i.e. doctors) and patients. Citing a story from the s, he explains: ‘The usual procedure for a doctor when he reached the patient’s house was to greet the grandmother and aunts effusively and pat all the kids on the head before approaching the bedside.’ As time went on and science established its dominance, the doctor–patient relationship morphed away from the image d’Épinal, that is a clichéd or stereotypical representation of the old country doctor (usually a man), in favour of ‘diagnostic imaging and laboratory tests’. Put otherwise, touch and contact were kept at bay, no longer providing the psychological healing they once did. Country doctors no longer retained as prominent and as close a role as they once did. Geographically, too, they remained more distant and less present in the social fabric, to much of the patients’ regret. I would further argue that Shorter’s account is in fact dismissive of medical practice as performed by the ‘anachronistic old doc’, as though nothing was worth preserving. Ironically, Shorter concludes, medicine may have reached a point where it is able to provide answers and solutions to disease, but it fails to override the patient’s nostalgic longings for a caring, though perhaps idealized, ‘old doc’ who would take time to visit and care. In turn, the field of medicine has been facing growing distrust and dissatisfaction. He notes: ‘At the very moment that science has conferred success over much of the vast range of disease that plagues humanity, the crown of victory has been snatched from the physician’s head.’ In the French context of the nineteenth century, the country doctor became such a central figure that it inspired a brand-new literary genre, the roman médical, or medical novel, that continues to influence people’s conception of care. As François Tonnellier explains, the country doctor offered ‘a traditional vision of medicine’ and ‘evok[ed] foundational social values: the good, humanist, heroic doctor, who works in a peaceful and fertile
Edward Shorter, ‘Primary Care’, in The Cambridge History of Medicine, ed. by Ray Porter (New York: Cambridge University Press, ), p. . Shorter, p. . Shorter, p. . Here I am rather struck by Shorter’s structural and stylistics choices that paint the history of primary care as a move from a point where patients dictated their needs to a contemporary moment where doctors could finally exert the power and authority conferred upon them by scientific knowledge, if only patients did not require them to engage in personal exchanges. The terminology ‘crown of victory’ also exacerbates the idea of competition or opposition between patient and doctor, positing the latter on top of social hierarchies.
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countryside, away from the hustle and bustle of the cities’. The values, vision, and the doctors’ working conditions have certainly changed, but a majority of French people still ‘want doctors close to home’. This proximity should be understood both from a spatial and psychological viewpoint influenced by past representations, including literary ones, even if the medical novel genre – which, from a narratological perspective primarily ‘considers disease through the eyes of a doctor’ – does not offer homogeneous or unequivocal portrayals of its main protagonist. Writers such as Flaubert or Maupassant proved quite critical of doctors who, they argued, overuse ‘scientific jargon’ and are only ‘guided by capitalism’. In the twentieth century, other varying examples included Proust who also described physicians as greedy, or Céline’s enthusiastic young medical student in Voyage au bout de la nuit (Journey to the End of the Night) (), who is soon disillusioned by war, death, and the meaninglessness of the world. As time passed, stories shifted focus from the doctor to disease and then the sick, but health/care remained a key concern. The HIV/AIDS crisis of the s and s is another key illustration of this new literary paradigm when (French) queer writers living with the virus took to writing to not only showcase the suffering, trauma, and solidarity within their community, but also to challenge biomedical discourse and regain some control over dehumanizing medical and governmental responses. In similar ways, Édouard Louis focuses on another precarious community and makes a point to describe the material and human poverty of his home and village in detail. In addition to relying on a lexicon grounded in dirt, bodily fluids, and foul smells – in turn, representing social reproduction in a manner akin to contagion or viral reproduction – he writes about the ‘towns and working-class landscapes of the North’ and adds that ‘[t]hey provoke a disgust at daily life . . . Those houses, those reddish buildings, those austere factories with their dizzying chimneys always spewing out a dense, heavy, bright white smoke, never letting up.’
François Tonnellier, ‘Le médecin de campagne, ou l’ambiguïté des symboles’, Les Tribunes de la santé, , (), – (p. ). ‘Les français veulent des médecins à proximité et moins d’impôts’, Mediapart, April [accessed July ]. ‘Les français’, p. . ‘Les français’, p. . See Loïc Bourdeau and V. Hunter Capps, Revisiting HIV/AIDS in French Culture: Raw Matters (Lanham: Lexington Books, ). Édouard Louis, The End of Eddy, trans. by Michael Lucey (New York: Farrar, Straus and Giroux, ), p. .
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Following controversies in the French media, Louis published childhood photographs to support his version of events; these clearly depart from bucolic portrayals of provincial France. From the first chapter of The End of Eddy onward, pain is at the heart of the narrative, be it psychological (insults, homophobia) or physical (disease, abuse). Though only two chapter titles refer directly to suffering and/or medicine, ‘Pain’ and ‘On Why Man Don’t Trust Doctors’, Louis constantly returns to healthcare problems. In this novel alone, he mentions doctors over thirty times, and, while they are important to the story, they remain distant and disconnected figures who seem to understand little about the geographical, social, and financial conditions of the milieu in which they intervene so often. In ‘Village Stories’, Louis also explains: ‘There were more people with disabilities in my family than in others. Or maybe we hid it less, or had less medical attention, or didn’t know how to handle it. Or perhaps it was just the lack of money for appropriate medical care, that and a hostile attitude toward medicine.’ The particular relationship between Louis’s family and health/healthcare is embedded in several processes of social domination, that is, a form of systemic oppression that ranges from underfunded education, limited access to healthcare, ever-diminishing welfare benefits, and the widescale stigmatization of working-class and poor populations as lazy, lewd, and ignorant. Poverty is without doubt the leading factor that prevents any possibility of betterment. It is worth noting, too, that while they seem to stand out from the village crowd, it might simply be a matter of visibility (‘we hid it less’). Overall, health-related interventions are shown to have limited medical impact on the sick, and the family’s GP does not demonstrate the caring touch of the idealized old country doctor. His mere presence in the home in fact triggers behavioural changes. Louis recounts in the text about his mother: ‘[When] the doctor would visit at night . . . our bodies would change on his account, we would hold ourselves differently, we would speak differently, . . . we were afraid that one gesture would reveal our social inferiority.’ The power of Louis’s work lies in its ability to make a singular story resonate with many. Indeed, this instance is not an isolated case. It is this embodied change, distrust, and fear that interests me here as it speaks to wider healthcare issues in France.
Louis, The End of Eddy, p. . Édouard Louis, Combats et metamorphoses d’une femme (Paris: Seuil, ), p. . In a philosophical essay on disease and drawing on his experience with cancer, Ruwen Ogien explains that ‘by acting like the “good patient”, [the patient] only shows a more or less intuitive understanding of the existence of an asymetric power relation’, which resonates with Louis’s family.
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The past ten years have seen the increase in studies on social class and healthcare. Thanks to scholarly contributions such as Anne-Marie Arborio and Marie-Hélène Lechien’s study of ‘the relations between the working class and doctors, while prioritizing the viewpoints of the former’ or journalistic interventions such as Miguel Shema’s exploration of ‘the way that one’s habitus produces different interactions with healthcare’, it has become evident that (financial and geographical) health inequalities affect first and foremost poor and working-class individuals and those living away from urban centres. Not only do these individuals have restricted access to healthcare, but, when they do, they also experience differences in treatment. For instance, ‘those suffering from cancer are less informed about their illness when they belong to the working class’. Put differently, underprivileged patients do not receive as much information about their diagnoses and treatment options as less precarious patients. In , the French government passed a new law (n -) to address and reduce healthcare inequalities. Its effects have yet to be seen; the COVID- pandemic and reduced investments in infrastructures and wages in fact further exacerbate the problem. Yet, beyond necessary financial means, the hierarchical and paternalistic character of the patient–doctor relationship needs to be discarded in order to truly move beyond ‘hostile attitudes’, distrust, and necessity. With regard to this last point, Arborio and Lechien show that working-class households operate
They do not wish to be seen as needy or poor. Ruwen Ogien, Mes Milles et Une Nuits (Paris: Albin Michel, ), p. . Anne-Marie Arborio and Marie-Hélène Lechien, ‘La bonne volonté sanitaire des classes populaires’, Sociologie, , (), – (p. ). Miguel Shema, ‘Les classes populaires et leur santé: nécessité de penser les habitus’, Médiapart, May [accessed June ]. Discrepancies also occur across racial lines. Still, the French Republican model does not include race/ethnicity in statistics and surveys. For studies that consider healthcare in France and questions of race/ethnicity, see Carolyn Sargeant and Stéphanie Larchanché, ‘The Construction of “Cultural Difference” and Its Therapeutic Significance in Immigrant Mental Health Services in France’, Culture, Medicine and Psychiatry, , (), –, or Carolyn Sargeant and Stéphanie Larchanché, ‘Disease, Risk, and Contagion: French Colonial and Postcolonial Constructions of “African” Bodies’, Journal of Bioethics Inquiry, , (), –. ‘Une médecine de classe’, Observatoire des inégalités, June [accessed June ]. See Florence Méréo, ‘Hôpital: l’appel de médecin à Emmanuel Macron pour relever durablement “un système de santé à genoux”’, Le Parisien, June [accessed June ]. In their letter to the French president, healthcare providers ask for more support as hospitals are struggling to provide satisfactory services or are forced to shut down entire wards. Louis, The End of Eddy, p. .
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according to a need-based approach and only visit their doctor when pain levels are high. Louis, who moved to a bigger city after spending his childhood in the village, remembers a time he was at home with his mother and felt sick: You were watching TV in the room where I was. You were the only one at home and I told you I was feeling poorly. I asked you to call the emergency doctor or the medics, but you refused. You inhaled smoke from your cigarette and told me it was nothing. I was aware of what was going on: for you, I was exaggerating my pain because I was behaving like city people . . . In our world, medicine and our interactions with doctors had always been seen as a way for the bourgeoisie to feel important . . . But the pain would not go away; I got off the couch and told you that I was going to see the doctor. . . . At the doctor’s office, he examined me and told me my appendix was about to burst. I spent two weeks at the hospital, the appendix was infected and the infection had spread through my body. The nurses had told me: A few hours later and you could have died from it.
Louis’s goal here is not to cast judgement on his mother. Rather, it is to provide a surgical reading of the dynamics that led to the mother’s undermining of his symptoms and his decision to see a doctor. If the need-based approach to care skews one’s perception of pain, it is also entwined in social power relations that pit the working class against the bourgeoisie. It is because Louis has experienced both milieus that he is able to go to the hospital. In his debut novel, he discusses his father’s serious back injury at the factory – an event to which he returns in his subsequent texts – and writes: ‘My mother told me that we needed to call the doctor, we had no choice, my father’s back had gone out’ (my emphasis). Louis himself ‘had inherited from [his] father this heedlessness where health problems were concerned. In fact, it was more than simply heedlessness, it was mistrust, it was hostility toward doctors and medicine.’ I will return to literature as a means to subvert power dynamics and ensure the constant subjectivation of those living in poverty. But here, it is important to bring forth the intricate relation between distrust (on the part of patients) and dismissal (on the part of carers). Shema’s reflection on habitus, the working class, and health shows that, for example, a number of providers refuse to take on CMU (Universal
Arborio and Lechien, p. . Louis, The End of Eddy, p. .
Louis, Combats et metamorphoses d’une femme, pp. –. Louis, The End of Eddy, p. .
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Medical Coverage) patients because they allegedly ‘do not attend their appointments, without giving notice, many are disrespectful’. This narrative, Shema notes, might just be a myth, which, regardless, fails to consider how ‘the temporality imposed upon the poor, by work demands for instance, does not allow them to have a free afternoon to visit their doctor, and it is also because medicine is perceived as aggressive and abusive’. In Louis’s work, abuse emerges in/is prompted by class interactions – all of which constantly remind the poor of their social status – and stems, in part, from an actual lack of holistic care, that is, a dismissal of underlying circumstances to medical conditions and of the consequences of health-related trauma. For instance, Louis’s mother recounts a miscarriage before she had him: It felt like I was constipated, my stomach hurt like when I’m constipated. I ran to the toilet, and then I heard the noise, plop. When I looked, I saw the little kid, and then I really had no idea what to do, I was scared, so like an idiot, I tried to flush, I had no fucking idea what to do. The damn kid didn’t want to disappear so I took the toilet brush to try to get him to go down as I flushed again. Then I called the doctor, he told me to go straight to the hospital, that it might be serious, and he had a listen and it wasn’t anything serious.
Although ‘she got a laugh out of telling’ this story again and again, the use of direct speech reveals a more vulnerable side to a traumatic event. As a sidenote, unpunctuated direct speech and the rendering of working-class language, a key stylistic component of Louis’s first novel, illustrate his commitment to not speak for others. Further, it makes audible voices that are seldomly heard and prevents a form of discursive hierarchization, which would afford the author or doctors more power by virtue of their social rank. Here, laughter seems to be a coping mechanism for someone who has faced a medical emergency and lacked information to make sense of it. The last sentence of the story (and of the paragraph), borrowing the doctor’s word (a diagnosis of sorts) – ‘it wasn’t anything serious’ – contrasts with the graphic account of child loss that in the end remains unexplained, untreated, and dismissed. Yet, it is the patient who continues to relive the fear, the guilt, and undermines themselves (‘like an idiot’), even if they laugh. Spending time away from the city with middle- and upper-class schoolmates and away from his parent’s language of necessity slowly changed Louis’s relation to care and provided him with new tools to
Shema. Shema. Louis, The End of Eddy, pp. –. Italics in original. Louis, The End of Eddy, p. .
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understand his family’s experiences with medicine. Literature has later given him the ability to expose their words and their wounds.
‘Tough Guys Don’t Care’ In the span of a decade, Louis has deployed his rich oeuvre – from novels and plays to political interventions and essays – guided by a creative ethics ‘to make art exist where it is usually absent’ and to give a voice to the vulnerable and the oppressed. In his work, women are by far ‘the “default” givers of care’. Yet, and as much as he uses literature as a platform to showcase a diversity of experiences of domination and oppression, Louis concerns himself more deeply with masculinity, the toxicity of which has pushed him, an effeminate gay man, out of his home town. Of interest to this contribution is thus the complex and tight relationship between men, masculinity, pain, and care that haunts his works. However, it is also crucial to first remember how gender differences lead to unequal healthcare practices and how women suffer most from these inequalities. In , the French High Council for Equality Between Women and Men (HCE) published a detailed report showing how gender expectations ‘influence the expression of symptoms, the relation to one’s body, one’s use of healthcare services’ and offered recommendations to encourage an intersectional approach to improve care. In her study, Cécile Stratonovitch has likewise shown that ‘medicine and other natural sciences contribute . . . to masculine domination’, women receive less attention in scientific research, and women’s illnesses are considered less serious. Within Louis’s poor, working-class environment, women do experience health issues (and domestic violence), but men seem most affected by pain and illness because of exploitative factory work. As I have mentioned, in each of his texts Louis brings up his father’s quasi-paralysing accident. According to a account, ‘a weight, hanging on cables, fell on him and broke his back. After that accident, he was
Tronto, p. . Ken Loach and Édouard Louis, Dialogue sur l’art et la politique (Paris: PUF, ), p. . Tronto, p. . ‘Prendre en compte le sexe et le genre pour mieux soigner: un enjeu de santé publique’, Haut Conseil pour l’Égalité () [accessed June ] (p. ). Cécile Stratonovitch, ‘Genre et médecine’, ERES, , (), – (p. ).
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immobilized for years.’ Interestingly in The End of Eddy, the story is slightly different, placing the blame on the father: [T]he factory called my mother: Your husband’s back gave out all of a sudden . . . Then the doctor came on the line (or else it was my father himself ) Your husband was carrying weights that were much too heavy for him at the factory, and for much too long a time. He should have realized it sooner and taken precautions. (But you know, Jackie doesn’t like doctors, he doesn’t trust them, he won’t take his medicine . . . He’s going to have to stop working for an indefinite period of time.
At the very moment that he experiences pain and the news of long-term disability (and unemployment), he does not receive attentive care but reprimands and blame as though his actions had occurred in a vacuum, as though he alone had brought this upon himself. Yet, the factory is by law required to provide training on how to perform a task in the most ergonomic manner; safety precautions are also the employer’s responsibility. As for healthcare, distrust towards doctors and medications is posited as the father’s sole responsibility without any consideration for power and class dynamics that contribute to the situation. Earlier in the novel, Louis explains that ‘[t]here is a way in which people do grow accustomed to pain, the way workers get used to back pain . . . without realizing that these problems were not the cause, but rather the result of . . . punishing workday[s]’. Throughout his work, Louis highlights the processes of symbolic violence that further exacerbate physical pain. In addition to living in poverty, dealing with bad health and work accidents, the poor come to believe that they are responsible for it all and refuse to be seen as victims. Yet, Louis argues, ‘[t]he word “victimization” is a rhetorical and political strategy by those in power to reduce the dominated to a form of shame and silence’. Within Louis’s (childhood) environment and given the patriarchal order in place, to be a victim also carries undesirable gender stereotypes of weakness and femininity. This very order thus plays a crucial, damaging role in men’s healthcare. Indeed, the villagers kept medicine and doctors at
Loach and Louis, p. . Louis, The End of Eddy, p. . Italics in original. In this instance, it is also interesting to consider the mother’s reaction: ‘But if he’s on unemployment that’ll mean less money, won’t it?’ (italics in original). While she could come across as uncaring or inconsiderate, it is in fact because she is so concerned about her family’s (financial) well-being that she makes such a comment. She understands that less money would worsen her living conditions and could increase domestic violence. To an extent, this response also subverts the idea that women care for others selflessly. Louis, The End of Eddy, p. . Louis, The End of Eddy, p. . Loach and Louis, p. .
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bay and ‘made a principle out of it[.] You won’t see me popping pills all the time, I’m no pussy.’ And just like social reproduction, this attitude is picked up by younger generations, including queer/gay men like Eddy/ Louis, who want to fit in: ‘Even today, I cannot help feeling a sort of repulsion at the idea of ingesting antibiotics or of calling a doctor.’ Because ‘the image persists that what it means to be a man is not to care, or, at least, not to care well’, poor and working-class men end up unattended to and broken. Overall, they are losers in a bourgeois and medical system that despises their masculinity and considers their living conditions and poor health only as the direct consequences of their actions and choices. Medicine, however, does not function in a vacuum. Louis’s constant return to this accident serves as a reminder of the chronic pain that his father (and co-workers) endures. The repeated act of writing the event indeed mimics the ongoing physical suffering and seeks to shed light on the contributing factors: ‘I only want to write the same story, again and again, to return to it until it makes visible fragments of its truth.’ By chronicling the accident over the years – in order to both give a factual account and to record it for literary posterity – Louis seeks the whole truth and, more importantly perhaps, reminds us that doctors are equally entangled in networks of power and ‘do not escape the influence of [their] social, historical, political, ideological context’. The anonymity of each doctor reminds us, too, that they are not the main focus of his stories, that they stand more generally for the French medical institution as a whole and that their services are intertwined with governmental policies. In the Who Killed My Father, adapted for theatre in Paris and Berlin, Louis openly calls out politicians and holds them accountable for passing laws that directly affect and further impoverish poor and working-class people. His use of dates in bold (‘In March ’, ‘In ’, ‘In ’) resemble a medical file that lists aggravating circumstances from discontinued coverage of pain medications to reduced welfare allowances and forced return to work despite the father’s disability. French presidents Jacques
Édouard Louis, The End of Eddy, p. . Italics in original. Édouard Louis, The End of Eddy, pp. –. See also p. : Louis remembers walking on a nail and hurting his foot. He hid the injury for days until he finally tried to disinfect with his mother’s perfume for fear of getting tetanus. Tronto, p. . Loach and Louis, p. . Edwige Comoy Fusaro, ‘Avant-propos à la section “Littérature et Médecine”’, Cahiers de Narratologie, (), – (p. ). Louis, Qui a tué mon père, pp. –.
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Chirac, Nicolas Sarkozy, François Hollande, and other politicians are all responsible: they each ‘broke [his father’s] back all over again’. It appears then that writing operates a form of diagnostic, of reading signs, and perhaps performs the real act of care.
Caring Relations and Healing Literature According to French writer Camille Laurens, ‘[t]he doctor and the writer do the same work: they read signs. Whether these signs are produced by a body or by the world, it’s always about deciphering and interpreting them.’ Edwige Comoy Fusaro proposes that ‘the doctor must interpret the signs of a body . . . without losing sight of a patient’s idiosyncrasy’. More recently, too, French writer Olivier Cadiot explains that writing requires care and attention ‘like one cares for a sick body’ and proposes that perhaps ‘the text is the patient’. These examples are but few in a larger literary landscape that affords texts a privileged socio-cultural status, if not as healers, at least as readers of symptoms or ailments. Indeed, Gefen, mentioned earlier, remarked on a ‘narrative’s ability to put us in someone else’s shoes to experience their emotions and understand their position in the most difficult situations’. In the realm of popular culture and self-help literature (or pop-psychology), Matt Phillips, in his analysis of writings by author and bibliotherapist Régine Detambel, likewise explains that ‘[r]ecent years have seen the publication in France of a bounty of mass-market non-fiction vaunting literature’s therapeutic powers’. While Louis does not speak of his work in medical or therapeutic terms, he nevertheless operates within the same framework and denotes similar intentions of repairing old wounds. The role that literature and medicine play in his work further attests to his commitment to ‘explain and understand’ life, like a doctor would work to understand illness. That he returns to the same stories from different angles – in a manner akin to different medical specialists examining the same
Louis, Qui a tué mon père, p. . Camille Laurens, Philippe (Paris: Folio, ), p. . Fusaro, p. . ‘Les bonnes paroles d’Olivier Cadiot’, L’heure bleue, January [accessed June ]. Gefen, p. . Matt Phillips, ‘On Bibliotherapy: Literature as Therapy and the Problem of Autonomy, with Régine Detambel’s Les livres prennent soin de nous’, Australian Journal of French Studies, , (), – (p. ). Louis, Combats et metamorphoses d’une femme, p. .
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patient – allows him to both get a closer look at the wound and its causes and simultaneously apply stitches to help it heal. What if, then, as Cadiot says, the text is the patient? Are readers, then, its doctors? To consider the text as a patient is in fact not such a foreign concept for literary scholars who examine narratives, dissect paragraphs, pay attention to each word, and try to give life to the entire body of the text. Each page reveals new symptoms that inform our judgement and understanding of the overall project. I would, however, argue that the text resists pathologization as it rejects any definitive or uniform interpretation. But, in any case, if the book – that which is supposed to provide help and healing – is also a patient, then it might be that literature effects change not because, like a doctor, it possesses exclusive knowledge and authority on a subject matter, but because it provides the very experience and account of that subject matter. To an extent, the dynamic at play is more of a patientto-patient interaction (like a support group) grounded in personal, emotional, and subjective knowledge. Louis seems to embrace this nonhierarchical dynamic; it is about moving away from the medical or clinical perspective and gaze, which nineteenth-century scientific developments exacerbated, and refusing to pathologize himself or his family. Indeed, although his writing highlights the working of power relations and places blame on specific individuals, it does not engage in a form of diagnosing that would be linked to a narrative of cure; the villagers are not sick, the system is. The inclusion of medical events and doctors in his texts thus serves to paint a more comprehensive portrait of the networks of institutional domination that contribute to the embodied violence and pain experienced by those living in poverty, while ensuring their constant subjectivation. In Caring Democracy, Joan C. Tronto – in line with Carol Gilligan’s earlier work on the ethics of care – reminds the reader that ‘care is about relationship. And relationships require, more than anything else, two things: sufficient time and proximity.’ Literature in general, and for Louis specifically, affords the writer and the reader this unique position, this access to ‘sufficient time and proximity’. Louis’s choice to write a polyphonic first novel with the inclusion of direct speech (in italics) without any punctuation marks further illustrates the breaking down of hierarchies of knowledge. The health-related stories and the voices of doctors or government officials are posited, in a reparative turn, at the same textual level as everyone else’s. Each text thus gives back or returns
Michel Foucault, Naissance de la clinique (Paris: PUF, [] ).
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power, agency, and the possibility of speaking up to the patient. It is not about dismissing the doctor’s knowledge and expertise; it is about enriching the medical approach with lived experiences in a context of poverty that constantly erases them. In this sense, Louis’s work resonates with the very principle of narrative medicine, which Rita Charon has theorized as follows: ‘Without the narrative acts of telling and being heard, the patient cannot convey to anyone else – or to self – what he or she is going through.’ Let the reader not be fooled by the book’s apparent passive nature; stuck in our hands it seems powerless like a patient under the potent gaze of a doctor reading a chart. The text manipulates us by transporting us into a world of unknowing, making us face new realities. I speak here not of the text’s intentions (of which it is devoid), and agree with Josie Billington that ‘[a]ny therapeutic effect of literature arises precisely from literature’s never trying or meaning to be a therapy’, but more broadly of the possibility that literature offers to reassess power dynamics. I also speak here of the non-fixity of positions, hierarchies, and identities and of the new modes of being in the world that literature, and Louis’s writing, bring about.
Towards a True Caring Democracy? Tronto writes that ‘[d]emocratic processes are required to assure that the voices of all people, not just the powerful, middle class, and so forth, are heard’. In contemporary French literature, a process of democratization has been unfolding thus giving visibility to more diverse authors and stories. Édouard Louis is one such voice which remains committed to shedding light on vulnerable and forgotten lives. As he reopens and exposes the wound(s) of his past, he offers some reparation. By pointing out everything that is wrong, he also makes the case for better funded healthcare, investments in education, robust welfare schemes, and more inclusive and supportive models of community, sociality, and relationality. Still, there remains one quandary with which I started this analysis. The experiences of poverty or vulnerability, which he makes visible and advocates for in literature, on social media, on stage, or on television, still require mediation through his cultural capital and a complex media system
Rita Charon, Narrative Medicine: Honoring the Stories of Illness (New York: Oxford University Press, ), p. . Josie Billington, Is Literature Healthy? (Oxford: Oxford University Press, ), p. . Tronto, p. .
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that consecrates or dismisses new writers. If we are asking healthcare professionals to listen carefully to stories, ‘to recognize the plight of their patients, to extend empathy toward those who suffer, and to join honestly and courageously with patients in their struggles toward recovery’, we, as literary scholars, must likewise open our eyes and ears to stories that are published via non-traditional channels. Literature and medicine cannot remain disciplines that uphold elitist values and engage in practices disconnected from reality. Otherwise, poverty and its impact on one’s experiences will continue to be an overlooked category. Otherwise distrust and dismissal will continue to isolate and hurt. Otherwise we, literary scholars, will overlook many stories that offer equally valid strategies to disrupt hierarchies and oppressive power dynamics. Consider for example obstetrical and gynaecological violence. The terminology is rather recent, and its legal recognition is equally new. French literature however comprises a rich corpus, from Camille Laurens’ Philippe () to Julie Bonnie’s Chambre (Room ) (), that draws attention to the phenomenon and seeks to regain control over the discursive and physical violence exerted by uncaring health providers. Yet, to look at literature alone is, for instance, to miss the viral movement #PayeTonUterus – a movement similar to #metoo focused on ob/gyn violence – which has shored up a more diverse pool of stories, by women of colour, poor women, or women with disabilities. Indeed, since women have been taking to social media to share their own traumatic experiences with health professionals. These textual accounts are no less worthy of our scholarly attention than published ones. They even hold the same power of moving and touching us. As philosopher Matthew Fulkerson argues, ‘touch is a powerful conduit of emotional reactions . . . because it often brings us into direct contact with another person’. Touch – in the form of stories – thus carries the promise and possibility of being with, understanding, and caring for the other. But to be touched, we must listen.
Charon, p. . Matthew Fulkerson, The First Sense: A Philosophical Study of Human Touch (Cambridge, MA: MIT Press, ), p. .
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The Human Endeavour Bioethics and Biocapitalism in Don DeLillo’s Zero K Justin Omar Johnston
The origins of bioethics as a term, practice, and field are fuzzy and contested. For those seeking to root the ethical norms of medicine in ancient texts, the Greek ‘Hippocratic Oath’ ( BCE) and the Sanskrit ‘Charaka Samhita Oath of Initiation’ ( BCE– CE) often serve as monuments and models of early bioethical thought. Along similar lines, others cite Thomas Percival’s Medical Ethics () as the source of modern medical ethics, while some suggest that ‘bioethics may have been invented in June ’ with the publication of Mary Shelley’s novel Frankenstein, which reconstructs the myth of Prometheus as a ‘study in the ethics of biomedical research’. Most agree that the Nuremberg Code () marked a clear turning point by introducing ‘the category of consent’ to scientific research on human subjects. Indeed, for Guillaume Le Blanc, ‘bioethics seems to originate’ from a ‘reference to consent’ in the Nuremberg Code that builds a ‘bridge between the interests of the patient and the interests of medical research’, thus evoking ‘a new logic in which the dangers of medicine are recognized’. From the mid-s to the early s – in the aftermath of some major medical scandals, including the thalidomide disaster in Europe, the Tuskegee Institute syphilis experiments, and the publication of Henry Beecher’s exposé, ‘Ethics and Clinical Research’, in the New England Journal of Medicine – ‘bioethics’ became a recognizable term and praxis, mostly
Alastair V. Campbell, Bioethics: The Basics (London and New York: Routledge Press, ), p. . James A. Marcum, Humanizing Modern Medicine: An Introductory Philosophy of Medicine (New York: Springer Press, ), p. . Catherine Belling, ‘From Bioethics and Humanities to Biohumanities?’, Literature and Medicine, , (), – (p. ). Guillaume Le Blanc, ‘A Brief History of Bioethics’, in The Care of Life: Transdisciplinary Perspectives in Bioethics and Biopolitics, ed. by Miguel de Beistegui, Giuseppe Bianco, and Marjorie Gracieuse (London: Rowman & Littlefield, ), pp. – (p. ). Le Blanc, p. .
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grounded in biomedicine and philosophy, where it remains most firmly rooted today. Meanwhile, a great many celebrated novels, including Frankenstein (), The Island of Dr. Moreau (), Lilith’s Brood (), Jurassic Park (), Oryx and Crake (), and Never Let Me Go () attest to the enduring and unsurprising interest of literature in the complications of bioethics, not to mention the rich traditions of non-English works that centre bioethical dilemmas. Not incidentally, the interest has been mutual. In fact, medical schools regularly assign novels to help their students explore ethical questions related to intersubjectivity, consent, embodiment, close reading, and intersectional identities, to name only a few key areas of analysis. Indeed, the emerging field of literary narrative bioethics is now working to facilitate intellectual exchange between literary analysis and bioethics. Along those lines, this chapter will analyse how one contemporary novel, Zero K () by Don DeLillo, uses cryonics to examine the role of bioethics in transhumanist philosophy and neoliberal economic theory. More specifically, my analysis will focus on how the corporate entity at the centre of the novel evokes human nature to depoliticize, naturalize, and solicit consent from its client-patients. Before analysing Zero K’s treatment of consent, I will review the historical and formal relationships between consent forms, bioethics, and the rise of biocapitalism. Finally, the concluding section of this chapter will consider some of the underlying limitations of a humanist conception of literary bioethics.
Consent and Capital Under the link to ‘Bioethics’ on its website, the pharmaceutical company Novo Nordisk proudly reports: ‘Our bioethics policy sets our general operational guidelines and is consistent with our objective: to strive to be economically viable, socially responsible, and environmentally sound by considering each of these elements when making business decisions.’ For all its boilerplate language, the policy depicts bioethics as both foundational and auxiliary to other elements within the corporation. While bioethics ‘sets [their] operational guidelines’, it is also made ‘consistent
Rita Charon and others, The Principles and Practice of Narrative Medicine (Oxford: Oxford University Press, ). ‘Our Bioethics Policy’ (), Novo Nordisk [accessed March ].
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Bioethics and Biocapitalism in Don DeLillo’s Zero K
with [their] objective’, which is, in the final instance, to make profitable ‘business decisions’. Put differently, bioethics, in this context, is designed to buttress the underlying objectives of capital accumulation. To ensure its concordance, bioethicists at Novo Nordisk and other pharmaceutical and biotech corporations ‘collaborate with external partners to improve the understanding of bioethical dilemmas’, highlighting the hermeneutic role they assume in defining the networked field of bioethics. For Novo Nordisk, this network includes ‘rewarding partnerships with University of Copenhagen, UNESCO, LRN [Legal Research Network], and Responsible Business Solutions’. And for its efforts, Novo Nordisk reports that these partnerships have yielded ‘e-learning tools [that] target employees and managers in companies, as well as students and organisations worldwide’. By its estimation, ‘the tools are generic and applicable within business training, academic teaching, and inter-governmental organisations’. In other words, Novo Nordisk ‘target[s]’ universities, corporations, and governments with ‘tools’ that define bioethics, in and of itself, as a ‘generic’ tool for assembling profitable networks of public and private collaborators. In this way, Novo Nordisk’s strategies resemble other biotech and pharmaceutical giants, including Pfizer, Johnson & Johnson, and Roche, to name only a few, who use similar methods and arguments. Given the banal ubiquity of these kinds of arrangements, bioethics has become, as Melinda Cooper and Catherine Waldby put it, ‘a crucial component of the normative and legal infrastructure regulating the political economy of the life sciences, even when bioethics assumes a principled opposition to the body’s commodification’. Although bioethics has its own rich history and complicated aims, it has also, often inadvertently, stabilized and channelled the expansion of the bioeconomy. Indeed, some of the most important ‘conceptual categories used in bioethics, particularly compensation, inducement, and consent’, precipitated the rise of contract research organizations, patient recruitment organizations (PROs), and
Novo Nordisk, ‘Our Bioethics Policy’. Novo Nordisk, ‘Our Bioethics Policy’. ‘Ensuring (Bio)ethics Means Acting with Equity’, Pfizer [accessed March ]. ‘Decisions Guided Through a Bioethical Lens’, Johnson & Johnson [accessed March ]. ‘Resolving Ethical Conflicts: Scientific Ethics Advisory Group’, Roche [accessed March ]. Melinda Cooper and Catherine Waldby, Clinical Labor: Tissue Donations and Research Subjects in the Global Bioeconomy (Durham and London: Duke University Press, ), p. .
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other forms of biomedical outsourcing and subcontracting. For example, in many prominent forms of Western bioethics discourse, ‘tissue donation and research participation are not understood or analysed as forms of work’ but are instead ‘regulated through the conceptual and institutional frameworks of bioethics’ where anything like a wage might constitute an undue inducement. How much money constitutes an inducement is, of course, relative, and many third-party recruiters specialize in finding clinical subjects who are indebted, underemployed, uninsured, living abroad, or otherwise economically precarious. What might be fair compensation for volunteers in one population could be an enticingly large sum for a population targeted by PROs. But Cooper and Waldby point to a still deeper rot: formal and historical interdependencies between bioethics and neoliberal (bio)capitalism. The ‘implicit contractualism of bioethical administration, the immense weight placed on the act of consent to indicate . . . voluntary acceptance of risk’ is not merely an ‘exceptional or extreme manifestation of the underground economy’. Rather, this notion of contractual consent and acceptance of individual risk ‘is emblematic of the conditions of twenty-first-century labor’ writ large. Indeed, in the s and s, well before the creation of institutional review boards, the Rockefeller Institute, the Committee on Medical Research, the Army Epidemiology Board, and the National Foundation already made their research subjects sign ‘consent documents’ with ‘waiver clauses’ that included ‘a description of the experiment being conducted and an affirmation of the subject’s willingness to participate’. From the outset, lawyers helped tailor these consent forms to insure against litigation by outsourcing the risks of the experiments. And in many ways, these consent documents were critical precursors for the short-term contracts that individuals now often sign for outsourced, casual, or temporary work, especially in how they shift systemic risks from employers onto the bodies of individual workers.
Transhumanist Convergence One way that the medical humanities has sought to reconsider bioethics and the experiences of workers, patients, and non-humans within
Cooper and Waldby, p. . Cooper and Waldby, p. . Cooper and Waldby, pp. , . Sydney A. Halpern, Lesser Harms: The Morality of Risk in Medical Research (Chicago: University of Chicago Press, ), pp. –.
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contemporary biomedicine is by turning to literature, specifically novels, for insight. I would argue that, at its best, literature situates bioethics as emphatically biopolitical, especially when representing ethical dilemmas that are embedded within multiple discursive conflicts. For example, ‘consent’ only has meaning in a novel because it can be read alongside and against various configurations of power and language that leave their mark on the text and in the world. In other words, novels can make visible what counts as ‘consent’, for whom, in relation to what social order, and under what historical circumstances. Indeed, the conceptual frameworks for consent, inducement, and compensation can only adequately be understood by tracing the social and historical contexts that condition them. Accordingly, literary narrative bioethics does not seek to advance ahistorical universal principals, which can be quite alienating. Instead, as Rita Charon affirms, literary narrative bioethics can ‘enable us to raise our ethical sights above the local toward the contemplation of a justice for more than a few’. Significantly, this approach emerges from and alongside feminist bioethics and feminist conceptions of relationality, care, and embodiment. Indeed, feminist bioethicists such as Susan Sherwin have argued that ‘we must go beyond the standard bioethical requirements for informed consent’, but moreover, Sherwin calls for a feminist relational bioethics that thinks ‘not only about how to change the individual patient or her provider (as is the pattern in non-relational bioethics) but also how to change society’. Thus, what surfaces in many contemporary novels about biotechnology and medicine are populations struggling to find agency and belonging in contexts where bioethics has become a node in biocapitalism’s network of collaborators. By biocapitalism, I am referring to the modes of technological (re)production and financial speculation that have emerged alongside contemporary biotechnologies since the s, including various forms of tissue regeneration, synthetic biology, stem cell therapies, CRISPR-CAS gene editing, reproductive technologies, and biological markets. Biocapitalism is, thus, how speculative investments and the life sciences produce value from human, animal, and microbial bodies.
Rita Charon, ‘Deliver Us from Certainty: Training for Narrative Ethics’, in The Principles and Practice of Narrative Medicine, ed. by Rita Charon and others (Oxford: Oxford University Press, ), pp. – (p. ). Susan Sherwin, ‘Whither Bioethics?: How Feminism Can Help Reorient Bioethics’, International Journal of Feminist Approaches to Bioethics, , (), – (p. ). Olivia Banner, Communicative Biocapitalism (Ann Arbor: University of Michigan Press, ), p. .
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Moreover, from a historical perspective, it is essential to recognize that the rise of the biotech industry in the US was instrumental in the sweeping transition from industrial to post-industrial capitalism and all the ideological changes this necessitated. After two oil shocks, a financial crisis, and increasing scientific concern about the degradation of natural resources (exemplified by the Club of Rome Report), Ronald Reagan sought to maintain and reassert US economic dominance through a massive ideological investment in post-industrial and biotechnological futures, which promised economic growth beyond the ecological limits of industrial production. The implications of these historical and political linkages are legible in contemporary novels such as Zero K, which explores and satirizes the role of transhumanism and bioethics in the context of overwhelming inequality. Apart from a short middle chapter, this first-person novel follows Jeffery Lockhart, the son of a billionaire, as he dates a single mother, finds work as a compliance and ethics officer, and, above all, travels back and forth from New York City to an underground cryonics facility where his father and stepmother seek biomedical transcendence and life everlasting. Surrounded by world-class doctors and transhumanist gurus, a community of ageing oligarchs live their final months in a sprawling high-tech bunker called Convergence, buried somewhere in southern Kazakhstan. Under medical supervision, these uber-rich patients choose to prematurely terminate their lives so doctors can cryogenically freeze their bodies under optimal conditions. As one of the on-site spiritual leaders explains: There is no arrangement to import the dead in shipping containers, one by one, from various parts of the world, and then place them in the chamber. The dead do not sign up beforehand and then die and then get sent here with all the means of preservation intact. They die here. They come here to die. This is their operational role.
Because the doctors and researchers at Convergence illegally euthanize patients in order to theoretically extend their lives, this facility plainly raises bioethical questions about physician-assisted suicide and informed consent, not to mention philosophical questions about what counts as death. Indeed, as Ross Lockhart, the narrator’s billionaire father, explains, ‘what is happening in this community is not just a creation of medical
Melinda Cooper, Life as Surplus: Biotechnology and Capitalism in the Neoliberal Era (Seattle: University of Washington Press, ), pp. –. Don DeLillo, Zero K (New York: Scribner, ), p. . Further references to this book are given after quotations in the text.
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Bioethics and Biocapitalism in Don DeLillo’s Zero K
science. There are [also] social theorists involved, and biologists, and futurists, and geneticists, and climatologists, and neuroscientists, and psychologists, and ethicists.’ As much as Convergence resembles an opulent hospice and research facility, it is also an underground space to showcase for clients the well-funded interdisciplinary work of humanists and social scientists. At the ‘philosophical heart’ of Convergence is a ‘stone room’ where ‘the people whose ideas and theories determine the shape of the endeavor’ sit on ‘backless benches’ with their ‘benefactors’ (). Here, the narrator, Jeff Lockhart, sceptically listens to a series of speeches that present the bioethical rationale for Convergence. Readers might expect to see the clichéd defense of cryonics: that ‘being cryonically suspended is the second worst thing that can happen to you’. Instead, the speakers overwhelmingly frame cryonics as an attempt ‘to design a response to whatever eventual calamity may strike the planet’, particularly climate change and its consequences (). In this way, the individual’s desire to escape death is reconfigured as both the expression and preservation of humanity’s spirit beyond planetary limits. Of course, this conceptualization of survival also reproduces neoliberalism’s aforementioned promise to surpass the ecological limits of industrial production via financial speculation, biotechnology, and outsourced labour. In both cases, the confrontation with Earth’s finitude engenders an effort to deep freeze the very social order that engineered the crisis. Thus, climate change functions at Convergence as the pretext for extending and securing the lives of select billionaires beyond a period of expected global war, after which they can re-emerge from their bunker to ‘own the future’, all supposedly in the name of humanity. Although Zero K is not exactly a work of science fiction since the efficacy of cryonics in the novel remains suspect, the novel is interested in how tropes from science fiction (cryonics, apocalypses) shape the imagination of those at Convergence. Like Evan Osnos’s revealing article, ‘Doomsday Prep for the Super-Rich’, Zero K also captures ‘a kind of real-world sci-fi, with gear’ that has suffused so many tech billionaires’ imagination of the future. Despite Convergence’s unrelenting focus on mass death, the survival of humanity is imaginable because human nature is defined as an enterprise.
Nick Bostrom, The Transhumanist FAQ: A General Introduction Version . (The World Transhumanist Association, ), p. . Evan Osnos, ‘Doomsday Prep for the Super-Rich’, The New Yorker Magazine, January [accessed August ].
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Indeed, returning to Convergence just before his father’s freezing, Jeff meets an unnamed ‘tall somber woman’ who explains to him that the ‘world, the one above . . . is being lost to systems. To the transparent networks that slowly occlude the flow of all those aspects of nature and character that distinguish humans from elevator buttons and doorbells’ (–). Since she appears to be one of the executives at Convergence, it is fair to say that the organization imagines itself, however ironically, as a refuge from the techno-scientific ‘systems’ that reduce the supposed sovereignty of human ‘nature and character’. At the same time, however, the ‘tall somber’ executive goes on to contend that ‘the subterrane is where the advanced model realizes itself. This is not submission to a set of difficult circumstances. This is simply where the human endeavor has found what it needs’ (–). In other words, the ‘advanced model’ of Convergence is not an emergency contingency plan; it is the realization of humanity’s true ‘nature and character’, which is to find ‘what it needs’, not to survive, but to ‘advance’. Preserving humanity – without preserving the planet – is thus simply part of the ‘human endeavor’ because humanity is the endeavour. To be sure, this formulation of human nature comes straight from transhumanist philosophy, and it is succinctly captured in Ray Kurzweil’s claim that ‘being human means being part of a civilization that seeks to extend its boundaries’, making Kurzweil’s promise of ‘transcending biology’ the quintessential humanist enterprise or ‘endeavor’. Accordingly, the speakers at Convergence are in the habit of making audacious pronouncements: they ‘want to stretch the boundaries of what it means to be human – stretch and then surpass’; their patients will ‘emerge in cyberhuman form’ as ‘ahistorical humans’. And yet, all these images of transformation are reassuringly rooted in the idea that human nature and ‘human glory [is] to refuse to accept a certain fate’, particularly death. Indeed, as one speaker at Convergence proclaims, ‘death is a cultural artifact, not a strict determination of what is humanly inevitable’ (). In other words, what is humanly possible is practically unlimited because, at Convergence, human nature is defined as a refusal: an abject refusal of death and an abject refusal of those systems that might entangle or occlude the ‘human endeavor’. Importantly, Convergence defines human nature negatively by what it is not, only to hold up this hollow term as an expression of humanity’s exceptional sovereignty.
Ray Kurzweil, The Singularity Is Near (New York: Penguin Books, ), p. .
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Bioethics and Biocapitalism in Don DeLillo’s Zero K
Human Capital: ‘A Way to Claim the Myth for Yourself’ To understand how the bioethics at Convergence does more than merely parrot the relatively obscure philosophy of transhumanism, it is worth recognizing how transhumanist ideas about human nature emerged from neoliberal thought and human capital theory. Developed primarily at the University of Chicago from to by Gary Becker, Jacob Mincer, and Theodore Shultz, human capital theory is the central conceptual breakthrough of neoliberal economics. According to human capital theory, every activity (or inactivity for that matter) increases or decreases one’s human capital. Initially, human capital sought to measure the impact that different activities would have on an individual’s future income, but over time, it expanded to also measure the impact of activities on one’s simple affects, like a sense of ‘satisfaction’ or increased self-esteem, regarding those too as returns on an investment. The importance of human capital theory ‘does not lie in a reformulation of economic theory, but in pushing back the boundaries of economics beyond the sphere of market transactions’. And this expansion of economic theory into every sphere of daily life is predicated on Jacob Mincer’s insight that ‘non-market activities are not necessarily extra-economic’. And because healthcare, along with education, is a major area of interest within human capital theory, it is unsurprising that economic concepts such as ‘risk analysis’, ‘opportunity costs’, and ‘incentives’ often accompany biomedical decision-making. Critically, if human capital theory suggests that you can always be more human because you can always increase your human capital, then, likewise, you can also never be human enough or fully human. Accordingly, neoliberal ideology treats being human as an aspirational enterprise that demands continual enhancements, and this is precisely the sort of humanism espoused at Convergence. Indeed, when the Stenmark twins, two of the featured speakers at Convergence, admit that their brutal depictions of global collapse might ‘act as disincentives’ for some, they decide to end their speech by pitching their argument in more explicitly economic terms, a language their billionaire audience will surely find familiar. They begin this pivot by asking their clients, benefactors, and prospective patients to ‘Think of Money and Immortality’:
Jacob Mincer, Human Capital and Economic Growth (Cambridge, MA: The National Bureau of Economic Research, ), p. . Mincer, p. .
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Here you are, collected, convened. Isn’t this what you’ve been waiting for? A way to claim the myth for yourselves. Life everlasting belongs to those of breathtaking wealth. Kings, queens, emperors, pharaohs. It’s no longer a teasing whisper you hear in your sleep. This is real. You can think beyond the godlike touch of fingertip billions. Take the existential leap. Rewrite the sad grim grieving playscript of death in the usual manner . . . Isn’t the pod familiar to us from our time in the womb? And when we return, at what age will we find ourselves? Our choice, your choice. Just fill in the blanks on the application form. ()
Despite their extreme wealth and ‘godlike’ status, this community still suffers from the ‘teasing whisper’ of ‘death in the usual manner’, which represents an unacceptable limit on the power of their ‘fingertip billions’. Opposing a concept of humanity constituted through a shared mortality, Convergence points to a stratified conception of human belonging, a genealogy of ‘those with breathtaking wealth’. Yes, Convergence offers these ‘collected’ billionaires the ‘choice’ to ‘rewrite’ the tragic ‘grieving playscript’ of death. And yes, this is an ‘existential leap’, but this is also what allows them to ‘claim the myth for [them]selves’. They can now join ‘kings, queens, emperors, [and] pharaohs’ in everlasting belonging through their extreme wealth and their extreme endeavours to become more (than) human. Significantly, their endeavour is to cement and ontologize their class privilege by creating an ‘advanced model’ that invests in itself and can rejuvenate to the age of its ‘choice’. And while this supposedly entails an ‘existential leap’, it is also as ‘familiar as the womb’ and just ‘what [they’ve] been waiting for’: the return on an investment they’ve always expected from their exclusive position within private healthcare systems. Significantly, also in this passage, the Stenmark twins end their speech by highlighting the need to ‘fill in the blanks on the application form’, a contract that recalls biomedical consent forms (). While this form would be necessary and probably contains detailed disclosures about the risks of cryonics, this passage, and the novel as a whole, are much more interested in showing how consent is conditioned by fears of climate change and neoliberal understandings of enhancing human health. The consent form is pivotal, not for what it inscribes, but for the occasion it affords. It is the alibi for these interdisciplinary speeches; it provides the ‘operational guidelines’ that give the bioethical and humanist discourses an objective: getting
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Bioethics and Biocapitalism in Don DeLillo’s Zero K
the clients/patients to sign on the dotted line. The divisions between biophilosophy and marketing are so blurred here that Jeff eventually thinks, ‘this was not a sales pitch. I didn’t know what this was, a challenge, a taunt, a thrust at the vanity of the moneyed elect’ (). Of course, the ‘vanity of the moneyed elect’ is a form of inflated self-regard rationalized by human capital theory, but which is ostensibly wiped out in death. In biomedicine, the sales pitch becomes a ‘challenge, a taunt’ when subjects are not only asked to spend their money but also to invest and risk something more personal, their vitality, their bodies, their egos, and their human capital with the hopes of preserving it. In other words, biomedical consent in a neoliberal context is preconditioned by an economic conception of life that understands subjects as entrepreneurs for themselves. Within this ideology, human belonging also becomes aspirational, and the only way to feel connected to a larger community is by risking oneself to the human enterprise. Indeed, just before her scheduled freezing, Jeff’s stepmother, Artis, reassures Jeff that that she’s ‘studied the matter’ and understands the serious risks of cryonics (). Still, she remains committed to the procedure because it promises to advance the human endeavour: ‘skepticism of course. We need this. But at a certain point we begin to understand there’s something so much larger and enduring’ (). Artis’s consent is based on a vague desire to be part of an abstract community. But the only image of community represented at Convergence is, ironically, a highly individualistic vision of humanity, which is negatively defined by its abject refusal of anything that might limit its sovereignty. The willingness to risk oneself, by oneself, becomes the only way to see oneself as belonging to this ‘larger and enduring’ community of enterprising humans. Put differently, Artis’s consent is conditioned by the alignment of neoliberal humanism and transhumanism: the idea that you can always be more human and the idea that you can be more than human. While the tone of Zero K shifts between sincere bewilderment and satirical critique, the novel figures Convergence as a biomedical space where the contradictions of neoliberal humanism are so concentrated that they begin mutating into absurd and terrifying forms of transhumanism. This is legible, in part, because Jeff’s life in New York City offers readers an important comparison. Indeed, after returning to the city from Convergence, Jeff thinks ‘back in history now’ and, once again, the ‘days have names and numbers, a discernible sequence’ (). No longer hermetically sealed in Convergence’s tomb, Jeff’s return anticipates his parents’ potential thawing, and the fact that they too can never really
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escape history and the social markers of its progression. Nevertheless, like those at Convergence, Jeff and the rest of the city are preoccupied with securing themselves from catastrophe and improving their human capital. For Jeff, this takes the form of finding a new career as a ‘compliance and ethics officer’ and compulsively checking his keys, wallet, stove, and door lock: I keep checking the stove after turning off the burners. At night I make sure the door is locked and then go back to whatever I was doing but eventually sneak back to the door, inspect the lock, twist the door handle in order to verify, confirm, test the truth of, before going to bed. When did this begin? I walk down the street checking my wallet and then my keys. Wallet in left rear pocket, keys in right front. ()
Jeff is seized by an uncertain and unquenchable fear that persists no matter how many times he double-checks his pockets. In this context, the door lock and key synecdochally stand in not only for the bunkers at Convergence, but also for more general attitudes about securitizing domestic spaces in preparation for possible catastrophes. This attitude, of course, is crystallized at Convergence, where the ‘dynamic enclave’ promises ‘safe air’ and protection from both ‘climate and cosmic upheaval’, and from ‘the rebels, the volunteers, the insurgents, the separatists, the activists, the militants, the dissidents’ (). But it is also omnipresent in the city. Near ‘the Money Museum [and] the Police Museum’, Jeff notices, ‘stunted security markers set along the street’, not far from ‘the locked revolving doors of Deutsche Bank listening to the systems within, the networks of interacting components’ (–). Eventually, Jeff concludes that his apparently idiosyncratic compulsions are actually symptoms of a shared condition, ‘this [is] something people do, check the wallet, check the keys, it’s just another level of commonplace’ (). And in this small way, Jeff evokes an imagined community, one that links New York City and Convergence but does not rely on a universal conception of human nature. Indeed, rather than the transcendent concept of a convergence or singularity, Jeff imagines a more historically contingent notion of conjuncture, which reveals the common but uneven experience of prosthetic attachment and anxiety – an underlying fear of property loss – that some people with keys and wallets unthinkingly feel. A similar insecurity is also visible in Jeff’s dealings with money and the small discrepancies he finds in his bank account. While withdrawing money from an ATM, Jeff finds himself counting the bills ‘head down shoulders hunched, partitioned from people in the booths to either side of
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Bioethics and Biocapitalism in Don DeLillo’s Zero K
[him], isolated but aware, feeling their presence left and right’ (). Uncomfortably, in his ‘mind’s self-surveillance device’, he sees his ‘body crabbed tight’, seeming like ‘someone else, a recluse who’d wandered into semi-public view’ (). The booths’ partitions clearly signal that withdrawing money should be a private affair, but unlike at Convergence, they cannot shield users from the social world, the ‘feeling [of its] presence left and right’. Instead, the ‘mind’s self-surveillance’ negotiates between the cocooning logic of private capital and social pressure not to become a ‘recluse’. This productive tension also reappears when Jeff discovers ‘small persistent errors’ in his bank statements (). Even as his overall ‘totals diminish week by week’, he discovers ‘deviations from the logic of the numbers concept, the pure thrust of reliable numbers that determine one’s worth’ (). It is not, of course, that Jeff’s time in New York City represents an escape from the neoliberal logic that governs Convergence. On the contrary, Jeff is keenly aware of the ‘week by week’ decline of the numbers that determine his worth. It is the material, technical, and social interdependencies of the city that continually undermine any totalizing account of human capital or human nature.
Literary Bioethics: Humanism or Posthumanism Zero K offers a representation of bioethics as it is recruited in the transformation from neoliberal humanism into transhumanism. To counter this subsumption, the novel also suggests that bioethics can be found in spaces of interdependency and entanglement. This is a posthuman bioethics that stands in opposition to transhumanism. Rather than defining human nature by what it is not or who it refuses, posthumanism does not even seek to offer a conception of humans apart from their material and social relationships with animals, machines, and environments. Accordingly, a posthuman bioethics – much like feminist relational bioethics and literary narrative bioethics – could not conceive of consent without examining the web of relations across which power is distributed, blocked, rerouted, or shared. In this way consent is always plural, and bioethics is always a question of biopolitics. Nevertheless, I want to end this chapter by recognizing that this is not the only, nor even the most common way in which literary studies is imagined as a bioethical tool. Because literature grounds events in specific contexts, it is often seen as a reservoir and for the bioethics of ‘human nature’. For example, in a chapter entitled ‘The All-Importance of the Humanities’, E. O. Wilson, the renowned biologist and two-time Pulitzer
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Prize winner, argues that biomedical and biotechnological ‘change in the human condition’ poses a ‘problem best solved within the humanities’. In part, this is because the humanities, for Wilson, are ‘addicted to anthropocentricity’ and therefore analyse ‘the same old [human] story, with the same themes, the same archetypes, the same [human] emotions’ (). This is a useful narcissism, for Wilson, because the humanities’ supposed insularity also preserves a basic ‘existential conservatism’ (). That is, for Wilson, storytelling and literary studies function as bioethical enterprises charged with policing and promoting a conservative notion of human nature. Wilson’s understanding of the humanities is rooted in sociobiological premises that locate origins of human nature in prehistoric narratives about domestic and labour practices. According to Wilson, the ‘campsite’ functions as the prehistoric image of human ‘eusociality’ or ‘true sociality’, which is achieved when groups ‘divide labor through the surrender by some members of at least part of their personal reproduction in a way that increases the reproductive success of other members’ (). The campsite gives us hunters and gatherers, those who leave the campsite to hunt for meat and those who stay home to take care of the children. Because it is prehistorical, this social division is a structuring myth that hides alternative arrangements, internal conflicts, political struggles, protests, oppressions, or the dissatisfactions that surely accompanied the historically contingent era of campfire life. Unsurprisingly, this mythical image of campfire life also structures Wilson’s understanding of the sciences and humanities. Like hunters, the sciences seek meaty knowledge beyond the domestic sphere, ‘measur [ing] the dimensions of the real cosmos’ (). Alternatively, the humanities, which are clearly feminized in Wilson’s telling, reproduce culture norms and social bonds: ‘the social intelligence of the campsite-anchored prehumans . . . are best expressed in . . . [what] we have come to call the humanities’ (). Although ‘humanities scholars by and large have little grasp of the otherwise immense continuum of space-time on Earth’, they do know about the ‘tiny segments of continua’ that constitute their ‘small box of awareness’ around the campfire (, ). Significantly, then, when Wilson and others evoke the bioethical power of the humanities and
E. O. Wilson, The Meaning of Existence (Oxford: Oxford University Press, ), p. . Further references to this book are given after quotations in the text. Justin Omar Johnston, Posthuman Capital and Biotechnology in Contemporary Novels (Cham: Palgrave Macmillan Press, ), pp. –.
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Bioethics and Biocapitalism in Don DeLillo’s Zero K
storytelling, they are in fact referring to an entirely naturalized and depoliticized division of labour, knowledge, and gender that cannot be contested – especially not by the humanities – without collapsing the sociobiological basis of ‘human nature’. One thing that is troubling about a literary narrative bioethics rooted in human nature is that it is entirely compatible with the expansion of biocapitalism, even as it ostensibly resists it. Like many bioethicists and futurologists, Wilson predicts that in the coming decades new biotechnologies will inundate humans with bioethical dilemmas arising from ‘volitional evolution’, automation, and intelligent robotics: With more and more decision making and work done by robots, what will be left for humans to do? Do we really want to compete biologically with robot technology by using brain implants and genetically improved intelligence and social behavior? This choice would mean a sharp departure away from the human nature we have inherited, and a fundamental change in the human condition. ()
Labour is critical here. If competing with robots would ‘fundamentally’ alter human nature, then there is really only one thing ‘left for humans to do’: humanities work. In this telling, the humanities emerge as the bioethical (and biopolitical) site for surveilling, securitizing, and reproducing those social structures associated with protecting human nature. In a key passage Wilson explains: In time, after reaching an immense size and unimaginable complexity, [scientific discovery and technological advances] will certainly slow and stabilize at a much lower level of growth. Not to worry. By the time the process has set in, likely in this century, the role of science and high technology will, as expected, be beneficent and far more pervasive than now. But – and this is the most important part – science and technology will also be the same everywhere, for every civilized culture, subculture, and person. Sweden, the United States, Bhutan, and Zimbabwe will share the same information. What will continue to evolve and diversify almost infinitely are the humanities. ()
Here the century of biology eventually gives way to the epoch of the humanities, but only after every ‘civilized culture’ and ‘subculture’ has been ‘pervasively’ reorganized by the ‘immense size’ of techno-science. This is a dream of imperial dimensions. While the humanities may ‘diversify almost infinitely’, they must first be conditioned by a universal sameness – the ‘same everywhere’, the ‘same information’. Indeed, what counts as ‘civilized culture’ is here made synonymous with techno-
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scientific reforms that are supposedly neutral expressions of rationality, never mind the historical and economic inequalities that make technoscience qualitatively different in the United States (where corporations own millions of techno-scientific patents) and Zimbabwe (where corporations have mined minerals essential to Western science since at least when Cecil Rhodes of the British South African Company named the country Rhodesia, initiated white rule, and justified his actions as ‘promoting the best interest of humanity’). Wilson names this utopian world order ‘The New Enlightenment’, framing it as the completion, four centuries later, of Francis Bacon’s ‘empire of man’ (). Most importantly, then, the humanities serve as both the alibi for and the promise of biotechnological expansion. Like Novo Nordisk’s Bioethics Policy, Wilson sees the humanities as setting ‘operations guidelines’ for massive biotechnological growth, while nevertheless remaining ‘consistent with’ the ‘objectives’ of this civilizing mission. In this way, Wilson’s vision of a literary or humanities-based bioethics is actually very similar to the transhumanist and neoliberal visions of humanism seen in DeLillo’s Zero K. Human nature is preserved, cryogenically frozen in place, just so it can re-emerge after the techno-scientific storm passes to install the ‘empire of man’. But bioethics cannot be anthropocentrically limited to human ethics, particularly since most people have been only provisionally recognized as human, if at all. Nor can literary studies find itself employed by a bioethical system designed to police who or what counts as fully human, particularly in a neoliberal world where most people feel they’ll never have enough human capital to achieve a sense of belonging. In my view, literary narrative bioethics must resist this model of incorporation and role as guardians of humanity within a project of New Enlightenment. Rather than being frozen in time or sidelined to the campfire, a posthuman form of literary narrative bioethics – one that is methodologically tied to feminist relational theory – must tell the truth about the messiness of material relations and the historical structures of power that make those relations difficult to discern.
Johnston, pp. –.
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Re-framing and Re-forming Disability and Literature Susannah B. Mintz
Introduction ‘I fell down this morning, Borges’, writes Stephen Kuusisto in ‘Letter to Borges from Houston, Texas’, from his collection of missives to his aesthetic, spiritual, embodied forebear. ‘I blamed this on the pavement outside the hotel./There is something about falling when you’re blind, a kind of synesthesia occurs.’ The stumble becomes an occasion not for embarrassment or harm, but for a lesson in embodied knowledge. Rather than a retrospective account of a fall, the poem holds us in an experience – the speaker ‘falling’ into a ‘paradise of blue’, ‘falling into the world’, ‘[j]oyfully, falling’ – during which the speaker ‘had time to think’. Suspension in space is key to Kuusisto’s presentation of disability in epistemological terms, because it occasions a reappraisal of where, even what, everything is: what is the pavement, after all, if it is also the world the speaker falls into, and what is a man who also has ‘wings’, or ‘blue’, if it is less a colour than a possibility, a spur to memory? ‘Only God can conceal God’, the speaker thinks, which may have less to do with strictly divine omnipotence than with an idea about the circumstances in which we are most essentially ourselves. In solitude (‘No one was awake to see me’) the speaker’s relationships to time, spatial dimension, and something like sensory ‘accuracy’ shift to become expansive, jubilant, full of wonder. I begin with Kuusisto’s poem for the way it redesigns a disabled ontology in resistance to ableist norms. Blindness is not the ‘point’ of the text but simply its way of being. That is, the poem doesn’t so much make an argument about visual impairment as assume its legitimacy and value as a mode of existence, wherein to fall is not to lose dignity or bodily integrity but instead to laugh, find joy, establish intimacy, and retrieve memory. ‘Letter to Borges’ thus exemplifies both disability
Stephen Kuusisto, Letters to Borges (Port Townsend: Copper Canyon Press, ).
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‘cripistemology’, a way of knowing through and not despite impairment, and a crip poetics: literary form produced in response to a particular inhabitation of physical space. The interlocutor of Borges matters to this process, as a compatriot who might grasp the embodied quality of this sort of fall and so to confirm the speaker in what he knows, and to remind us that even something as apparently private as proprioception, the way a body feels itself in location, takes some of its meaning from the social worlds we inhabit, in which we grow up to learn how to comport ourselves. What is ‘nostalg[ic]’ about all this? Tripping may remind Kuusisto of childhood (he has written elsewhere of boyhood headfirst tilts across fields and sidewalks), but nostalgia seems less literal here than elemental; it is as if ‘falling when you’re blind’ might be equivalent to a cosmic tumble towards the very origin of it all: ‘falling into the world in the birth wind’. An early morning loss of balance becomes the originary moment of sensory reshuffling, and so without precisely announcing its pedagogical consequences, Kuusisto’s poem teaches us a new kind of embodied plenitude established in that most graceless of events, a faceplant on the pavement. To underscore Kuusisto’s sly but pointed achievement in transforming the stereotyped, clumsy ugliness of disability, consider the ex-cop paralysed by gunshot and the dwarf physician in Anne Holt’s crime novel – two characters thrown together by circumstance in the solution of a murder. The novel overtly interrogates the insidious dangers of Norwegian nationalism and homogeneity, and its protagonist, Hanne Wilhelmsen, is a staunchly anti-racist lesbian. Yet she is also depicted in the powerfully uninterrogated terms of a stereotypical cantankerous cripple who doesn’t leave her apartment for ‘weeks’ on end and ‘would prefer not to have anything to do with other people’. Dr Streng’s ‘circus-like appearance’, meanwhile, is carefully anatomized (he is ‘ centimetres tall’, with a head ‘far too big for his body’ and ‘even shorter’ arms) so that readers, along with Wilhelmsen, can’t help but ‘stare’. Conversation among other characters literally comes to a halt as Streng ‘passe[s] by’. It would be hard to fathom such renderings in a book otherwise so invested in the politics of ‘colourlessness’ – or to put this differently, a reader might not even notice what is problematic about such descriptions –
See Robert McRuer and Merri Lisa Johnson, ‘Cripistemologies: Introduction’, Journal of Literary & Cultural Disability Studies, , (), –. Anne Holt, (New York: Scribner, ). Holt, p. . Holt, p. . Holt, p. . Holt, p. . Holt, p. . Holt, p. .
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were it not for literary Disability Studies (DS), which trains us to be alert to the casual use of such tropes for symbolic purpose. Holt ‘metaphorizes’ disability, to quote Ato Quayson in another context, ‘even while trying to produce the entire narrative in scrupulously realist terms’. Injury ramps up the cliché of the disaffected sleuth waging a grouchy, reluctant fight against crime; her body manifests the very dangers of a world she is now determined to repudiate. On the other hand, caretaking and solace might arrive ‘even’ in the unlikely and comic form of a circus dwarf. I should make clear that doesn’t just trade in the worst sorts of ableist metaphors; Wilhelmsen’s positionality – her view of the goings-on from the height of a wheelchair – also suggests the epistemological turn in literary DS, where we move from the strictly representational to consider how disability invites alternative ways of being and understanding the world. The so-called cripistemology plays an especially important role in contemporary crime fiction, a genre defined by questions of knowing and of truth, and Holt’s novel does offer us a way of rethinking what social upheaval and orderliness mean through her variously non-normative heroine – and, in this novel, through a physician who is also differently embodied. We might say that Hanne Wilhemsen’s struggle is to hold onto a sense of herself when she is constantly being looked down upon, or that Magnus Streng, as a singular oddity, exposes the ‘dangerous stuff’ that is collective fears of otherness. We need these two as counterpoints to the armed officers who also appear in this novel as defenders of law and justice, because the wrongdoing at stake is directly attributable to the power dynamics of difference. The novel’s uncritical relationship to its characters’ anomalous bodies thus becomes a key factor in its ultimate message, which is that habitually doing things ‘in our Norwegian way’ – that is, insisting on identity cohesion and mocking multiculturalism – ‘[is] bound to lead to a crime’. In what follows, I will examine a selection of authors who challenge tropes of deviance, isolation, helplessness, and lack, and pursue Kuusisto’s re-framing of disability as a matter of creative knowing. This work not only revises an entrenched literary correlation between corporeal anomaly and something ‘unsavoury’ about a character or a milieu; it also re-forms how we might think about literary genres: not as structures aimed to contain,
Ato Quayson, Aesthetic Nervousness: Disability and the Crisis of Representation (New York: Columbia University Press, ), p. . See also Lili Paquet, ‘Disabling the Mainstream: Disability and Coming Out in Anne Holt’, Journal of Literary & Cultural Disability Studies, , (), –. Holt, p. . Holt, p. .
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explain, or ‘beautify’ the anomalous but as complex interactions between language, argument, and bodyminds that invite us to reconsider our assumptions. In the verse of a physician-poet who strives to make sense of his father’s dying through the cadences of classical literature; a fictional sculptor who views all her disabled boyfriends as raw material for her art; and a co-created graphic memoir of schizophrenia, impairment and illness become the source of creativity, if also the cause of suffering and shame, set in tension with such mechanisms of power as the law, medicine, and generic convention. This grouping of mental illness, mobility impairment, and cancer within a rubric of ‘disability’ must be alert to important variances in the lived experience of conditions that are felt, treated, and culturally represented in specific ways. Yet the predominance of ableism in the Western imagination means that otherwise divergent illnesses and impairments share in the oppressions of normative, and largely medicalized, attitudes about both body and mind. In turn, encounters with the healthcare system, or more generalized – and internalized – ableist metanarratives that shape cultural discourse about normalcy and value, exert enormous pressure on how writers engage with the most basic elements of their craft, from line breaks to plot. The overriding thematic of persistence and contestation in the texts discussed here is thus made all the more noteworthy. Disability becomes a form of gain, an artistically generative modality in which crip plots and poetics resist traditional paradigms and foreground disability’s rhetorical, imagistic, and narrative power.
Illness as Lyric Intimacy Charles Bardes’s Diary of Our Fatal Illness () is an extended prose poem that narrates the author’s father’s death from bladder cancer. Its particular poignancy is not just that Bardes deploys a heightened language to depict as well as transform the brute realities of illness, but also derives from the fact that Bardes is himself a practising physician. Where many US and UK authors writing with an awareness of illness and disability activism foreground their suspicion of the industry of medicine, Bardes might be
The term ‘bodymind’ originated with Margaret Price. See ‘The Bodymind Problem and the Possibilities of Pain’, Hypatia, , (), – (p. ). See H-Dirksen L. Bauman and Joseph J. Murray, ‘Deaf Studies in the st Century: “Deaf-Gain” and the Future of Human Diversity’, in The Disability Studies Reader, ed. by Lennard J. Davis, th edn (New York: Routledge, ), pp. –. Charles Bardes, Diary of Our Fatal Illness (Chicago: University of Chicago Press, ).
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inclined to defend his profession and to translate the physiology of cancer for a lay audience. Instead, Diary mythologizes the father’s experience with seemingly ‘unscientific’ rhetorical flourish, conflating ancient and modern in a way that is both subversive and full of reverent awe. Readers expecting the doctor to approach his subject with clinical precision will be disappointed; Bardes’s tactic is to represent himself as the physician-son who cannot explain why, who cannot fix his father, who can only listen, remember, and take care. Bardes’s slim volume is comprised of short lyric fragments that evoke classical poetry, the rhythms of psalm and prayer, the aphoristic condensation of parable and ballad, in which ordinary figures are cast as the personae of myth. The hospital becomes a temple; doctors are ‘sibyl [s]’ and ‘priests’; father and son alternately supplicants, celebrants, and prophets; disease a fanged ‘beast’, a pack of coyotes, the lord of the manor, and finally the companion who ‘walks beside you’. Because Bardes’s father had been in the Navy, he is both factually and symbolically an ancient mariner. References to sailors, boats, storms, sea gods, and mermaids abound, establishing one of several motifs in which the real (e.g. ‘a man who dove a submarine’, ‘ yo retired naval officer’) becomes indistinguishable from the fanciful – the father who names Poseidon, dreams of sailing to distant lands, becomes a ‘sleek porpoise[e] steering forward’. Diary suggests in its overarching conflations both a terrible irony – doctors are not, finally, immortal gods, and cannot make men so – and a different truth: that by ‘inspiring poets’ to their transformative and ‘memorializing’ work, we revere the most inglorious of human experiences. Importantly, then, it is as a poet that Bardes grants his father his ‘essential quality’ as a man (to invoke Hadrian once again), even when the son is cleaning the father’s ‘soiled clothes’ or ‘[prying] grime from under his nails’, and even though his status as a physician is not forgotten in these pages. Early on, ‘[m]y father said, What does that mean, you’re a doctor’, but straightforward answers to such questions (‘[m]aybe radiation’, ‘maybe chemo’) have no primacy here over Ovid, Shakespeare, or Kipling. This interplay between what we put our faith in as actual and the imaginary realms of legend and dream, in addition to the pastiche quality
The collection both invokes and resists conventional narrative tropes of illness as journey. See Anne Hunsaker Hawkins, Reconstructing Illness: Studies in Pathography (West Lafayette: Purdue University Press, ). Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. .
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of so many voices, sources, and tonal registers, is key to the poet’s own question of whether ‘the age of metaphor [has] passed’. This is a text in which everything is subject to ‘metamorphosis’; a stethoscope becomes a periscope, ‘[t]he sick man’s feet became hooves’, doctors and receptionists speak as if from the lines of medieval romance, language quoted from the father’s medical charts turns autobiographical and poetic. In a milieu defined by distortions, there is no singular moment of change, no radical transition from one state of being (hale) to another (sick), however pervasive the tendency to construe illness as estranging us from ourselves. (This is why narratives of illness so often employ tropes of journey and quest, to guarantee a distinction between the self and the sickness whereby the self remains in charge of its figurative navigation away from and back to home.) In Diary, there is only thick texture. And so the poet also wonders: ‘Might I not heal by word and hand. Did not the ancients cure by intoning charms . . . and was the healer not a poet. Did not the poet bend the cosmos . . . Does not the word expel disease’. The italics in these sentences signal an intrusion into one rhetorical context (medical chart) by another; this ‘I’ may or may not be the speaker who addresses his father, may or may not be one of many figures called ‘the doctor’ throughout the book. The son who tells his father unconditionally that ‘everyone dies’ is also the poet who knows that how we think about pain and sickness is as integral to our experience of it as dosages and lab results. We are ‘embarrassed by infirmity’, as the poem acknowledges – afraid of our own frailty, desperate to protect ourselves from the ‘unpleasant[ness]’ of coming too close to the vulnerable body. Bardes plays with the notion of identity putatively fractured by disease by ‘bending’ our confident sense of inhabiting a recognizable world where doctors do not say things like ‘lo’ and ‘verily’ and disease is not a rat but a thing that can be safely contained by drugs. There is a regimen at stake here, rounds of chemo and injunctions against alcohol, but there is also a physician-son who might not ‘know the way’. The regimen can make something happen, yes. But in words we can do, and be, anything, and that refashioning has potent social implications for how we respond to disease. It bears recalling, given the book’s dense metaphorical structure, Susan Sontag’s warning in Illness as Metaphor of the dangers of metaphorizing
Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. . See Susannah B. Mintz, Hurt and Pain: Literature and the Suffering Body (London: Bloomsbury, ). Bardes, p. . Bardes, p. . Bardes, p. .
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illness – specifically in dichotomies of victim and disease, or triumph and defeat, that covertly blame patients for ongoing illnesses and distract our attention from environmental causes and social attitudes that conspire to create disease as we know it. Does Bardes take disease seriously, on its own terms, or does he risk making it instrumental – turning it into something else, and so shielding us from direct confrontation with mortality? How do we know that when ‘[t]hey told me sickness refines a man’, we should interrogate rather than accept a cultural myth that sickness is only tolerable if it is also redemptive? What of the emptiness, the absurdity, of romanticizing sickness: ‘Did you not think that taking ill would give your life a purpose that it otherwise lacked?’ What tools does the volume provide to resist such entrenched condemnation of the ageing and infirm? The key to reading Diary of Our Fatal Illness lies in its very amplitude and archaism. Bardes seems to yearn backwards towards a mode of fable and wordplay that has no place in a consulting or operating room. But its staginess is a knowing one, rather than a retreat into the consolations (or obfuscations) of literary erudition. When the father refers to surgery as ‘two hours’ traffic of our stage’, we may detect the poet’s sly deflation of the pretensions of his own milieu; we are all but actors, as Macbeth realized only too late, casting ourselves into roles that satisfy our bottomless insecurities. But the point of it all isn’t to quit spinning tales; it’s to revel in the shape-shifting potential of language and so write ourselves into myths of our own making, ones that can powerfully refute the dehumanizing norms of the ‘house of sickness’. In the final lines of the book, father and child become ‘two ships two ditties two calm sleek porpoises steering forward with someplace to go’, and it is significant that in this final moment the father is returned not to health but to water (embryonic, baptismal, and merely natural), by the poetic rather than medical ministrations of his son. Bardes’s poetry does not eschew the certitudes of his field, internal medicine, but it does intimate that there is no such thing as ‘pure’ science somehow detachable from the lives of people who study or benefit from it. Cancer is situated in this text; it exists not as an essential thing with universal, ahistorical meaning but as a condition that will always be experienced in specific contexts that instruct us in how to think about it.
Susan Sontag, Illness as Metaphor and AIDS and Its Metaphors (New York: Picador, ). See also Martha Stoddard Holmes, ‘After Sontag: Reclaiming Metaphor’, Genre, , (Fall ), –. Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. . Bardes, p. .
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Becoming more nuanced ‘readers’ of illness, whether in ourselves or others, as professionals or not, is not solely a matter of more and better research. The demand of Diary is that we not skim, and equates dutiful readers of verse with capable thinkers about the questions that vex and intrigue scientists. When ‘the child reads the father story, page by page’, something is missing – is the child reading a story to the father or of the father? – that encapsulates the volume’s purpose. Reading a patient means reading the symptoms as well as the person, and reading to is always reading of because what we read should inform every aspect of interpersonal relation.
Disability as/and Art ‘This Todd’, one of the dozen stories in Nafissa Thompson-Spires’s awardwinning debut collection Heads of the Colored People, reads as an objectlesson in the perils of allyship. Thompson-Spires explains in an afterword that the book takes its title and its inspiration from nineteenth-century sketches of ‘black life from the mundane to the obscure’, and that her own stories are ‘preoccupied with black bodies and the betrayals of those bodies – both external and internal’. In interviews, the author has said that her collection ‘rethink[s] what’s allowed as authentically black’, that it offers ‘a different angle of black identity’. One effect of ‘This Todd’ is to legitimize unexceptional – that is, unmetaphorical – characters of colour with disabilities, to present them, if not protagonists of the story, then certainly as counter-discursive forces who jostle with a larger metanarrative about intersectionality. Disability operates in a few ways in this sly,
Bardes, p. . Nafissa Thompson-Spires, Heads of the Colored People (New York: Ink, ). Thompson-Spires, pp. –. Doug Gordon, ‘Author Nafissa Thompson-Spires Rethinks What It Means to Be “Authentically Black”’, Wisconsin Public Radio [accessed January ]. Diane Patrick, ‘Nafissa Thompson-Spires Finds a Place’, Publishers Weekly [accessed January ]. Thompson-Spires explains that she wrote the next story in the collection, ‘A Conversation about Bread’, so that ‘one of the disabled characters that Kim fetishizes in ‘This Todd’ would have a chance to speak back about the fetish – because it was important to me that the satire in that story was apparent.’ See also Nirmala Erevelles, ‘Race’, in Keywords for Disability Studies, ed. by Rachel Adams, Benjamin Reiss, and David Serlin (New York: NYU Press, ), pp. –; Therí Alyce Pickens, Black Madness: Mad Blackness (Durham: Duke University Press, ); Ellen Samuels, Fantasies of Identification: Disability, Gender, Race (New York: NYU Press, ); and Sami Schalk,
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trenchant investigation into what counts as ‘authentic’, given the uneasy historical and scholarly entanglements of disability and race. Neither a convenient slur nor a justification for the enslavement and dehumanizing of African and African American people, disability is only itself in the story: a feature of three men’s lived experience no more exceptional than other aspects of their corporeality, intellect, or memory. At the same time, the story’s narrator, Kim, maps her own needs onto the impaired body in a way that ignores each boyfriend’s unique interests. And in an even more layered sense, the dynamic between Kim and her disabled boyfriends both analogizes white liberal presumptions of ‘knowing’ – because preempting – Black experience, and points up the dangers in collapsing one subject position into the particulars of another. Kim is an artist and self-proclaimed advocate, who refers to a string of boyfriends, each with a different mobility impairment, as Todd (the first two are named Brian and Jamal). From the start, Kim conceals her objectification of these men behind an aestheticized appreciation of their bodies. Her descriptions are exact, poetic – she imagines the skin of thisTodd’s ‘stumps’ as ‘French-polished walnut’, then homes in on scars, ‘thread of a baseball’, ‘caked with clay and burnished dark’ – as if she is paying respectfully admiring attention. But is the visual assessment inappropriate? The story raises a compelling question about whether Kim’s fascination with her Todds is discomfiting because that attraction fetishizes disability or because readers might find the idea of beauty-indisability difficult to grasp. Both, ultimately, are true. In the story’s first paragraph, Kim nestles her head against the latest Todd’s shoulder ‘like a plinth for the Venus de Milo’, and moments later she admits that the Todds’ ‘likenesses and eccentricities have formed a frieze around the upper walls of [her] mind’. Even as she seems to acknowledge their unique subjectivities, the reductive underside to Kim’s apparently complimentary appraisals is thus betrayed; and if readers agree with Kim’s friend Chelsea that ‘it’s kinda weird’ for Kim to date only disabled men, then they may be guilty of perpetuating disability-phobic notions of sexual appeal. Kim may think her Todds are ‘nearly interchangeable’, but the story itself manoeuvres readers to catch us in any thoughtless acquiescence to disability as ‘weird’. Indictment works inside and outside the text.
Bodyminds Reimagined: (Dis)ability, Race, and Gender in Black Women’s Speculative Fiction (Durham: Duke University Press, ). Thomson-Spires, p. . Thomson-Spires, p. . Thomson-Spires, p. . See Thomson-Spires. Is this a sly reference to the three Deweys of Toni Morrison’s Sula, so named by the indominable, and disabled, matriarch Eva?
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That Kim is a sculptor allows ‘This Todd’ to make a wry comment on how an artistic relation to disability can become problematically prosthetic. Narrative prosthesis, as articulated by David T. Mitchell and Sharon L. Snyder, begins with the idea that disability ‘inaugurates an explanatory need’: as a deviation from normalcy, disability presents us with an interpretive conundrum. ‘What happened to you?’ succinctly captures interrogative horror in the face of evidence that something has gone ‘awry’, with a question that defines disability as a problem of individual damage and places the burden of responding to the non-disabled stare squarely on the ‘afflicted’ individual. Mitchell and Snyder argue that literary representation raises and answers the hermeneutic problem of disability in a prosthetic way, where body and text exist in a dynamic of reliance. If literature has made use of prevalent symbolic associations with disability as a convenient characterological device, so too has it then justified its existence as the mechanism whereby the difference of disability is erased – or, since a prosthesis can only ever approximate normativity, as the means of retrieving ‘an acceptable degree of difference’. Plot, in other words, exists to rehabilitate, if not eradicate, problematic bodies. The narrator of ‘This Todd’ uses her boyfriends in the prosthetic sense of bolstering a performative sense of self-righteous tolerance. ‘My friends aren’t always as sensitive as I am’, she boasts, and she becomes frustrated that the third Todd can’t ‘see the world in a slightly different way’, that he hasn’t yet ‘applied for those grad programs in disability studies’ they’ve apparently discussed – as if she knows best about the sort of disability experience, disability identity, he ought to have. Disability becomes a field of contest in which the narrator claims access to a privileged set of terms, belied by the very fact that Kim herself ‘still [doesn’t] know what to call any of these guys’ (‘differently abled’, ‘gimps’?), and settles on Todd because it’s ‘easier’. The hard work of intimacy doesn’t interest her as much as the virtue-signalling of public display, and she actively transforms each man into artwork throughout the tale – not just trying to figure out the best materials with which to ‘rende[r] the image’ of one Todd’s legs
David T. Mitchell and Sharon L. Snyder, Narrative Prosthesis: Disability and the Dependencies of Discourse (Ann Arbor: University of Michigan Press, ), p. . Mitchell and Snyder, p. . On staring, see Rosemarie Garland-Thomson, Staring: How We Look (Oxford: Oxford University Press, ). Mitchell and Snyder, p. . Thomson-Spires, p. . Thomson-Spires, p. . Thomson-Spires, p. . Thomson-Spires, p. .
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but in the way she stages encounters with non-disabled people to spotlight her control of the spectacle. In effect, Kim wants her Todds to be both less and more ‘disabled’, complaining when Jamal limps behind her, but on an excursion to Venice Beach with this-Todd – an activity to which he strenuously objects – ‘wish[ing] Todd had worn his uniform’ because the military signification would announce his impairment as heroic. The frustration with each relationship is that the men don’t conform to Kim’s ideas about, her own desire for, whatever ‘disability’ means. When a young girl points at Todd in his wheelchair, saying ‘Look’, ‘Look’, it’s Kim who ‘intervene[s]’, telling the mother, ‘“You really should teach your kid how to behave’ . . . ‘He’s a real person”’. But a real person can’t also double as proxy for Kim’s unvoiced needs. Kim is a distinctly unreliable, if also ‘relatable’, narrator, as we come steadily to understand, and the torsions of her perspective teach us something about how close to the surface our biases are, even (and especially) when we convince ourselves otherwise. Whatever her claims to acceptance, Kim reverts quickly to disability insult, particularly in moments when she actually quotes the Todds and thereby, as if inadvertently, demonstrates just how aware they are that she’s projecting her own ideas about disability onto them. Indulging a grotesque fantasy of harming Jamal (‘hack[ing] away’ at his limbs), she then ‘[tells] him his marionette legs [disgust]’ her. When this-Todd asks her to quit ‘staring’ at his stumps, she ‘trie[s] to invert the image’ and imagines herself ‘hunched in a wheelchair . . . like a defeated Blanche Hudson, only black and young and more beautiful’. When he complains, ‘it’s like you always expect me to be grateful’, she fails to differentiate between truly reciprocal attraction and the invasive, essentializing mechanisms of neoliberal affiliation. Staring at, infantilizing, and finally colonizing their personhood, Kim reduces the men to the single attribute of impairment and then disguises an exoticizing artistic interest as the ‘ability to overlook . . . shortcomings’. Kim’s tale encourages a kind of suspicion that destabilizes her authority even as it implicates readers in our own self-congratulatory attitudes. We can read ‘This Todd’ through Quayson’s concept of aesthetic ‘nervousness’ in that Kim’s attempt to represent her boyfriends according to an apparently progressive politics is ‘short-circuited in relation to disability’ – in other words, the actual
Thomson-Spires, p. . Thomson-Spires, p. . Quayson, p. .
Thomson-Spires, pp. –. Thomson-Spires, p. . Thomson-Spires, p. . Thomson-Spires, p. .
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disability experience of the Todds as they voice it continually interrupts, even derails, the narrative Kim creates for them. The apotheosis of Kim’s inability to think about disability as other than a problem in need of her benevolent assistance arrives in the form of actual prostheses – two carved legs, her gift to this-Todd. For two weeks, she says, ‘I carved and sanded and massaged the wood and plied and buffed and blew off the dust and buffed again. I engraved the soles of the feet with my signature and distinctive paraph.’ She announces, as if proudly, that she relied on ‘memory and intuition’ to ‘guesstimat[e]’ the necessary dimensions – which, of course, merely reinforces the fact that Kim is trying to refashion a Todd in her own image. These astonishingly outdated wooden legs, ‘far too heavy’ even to be used, become an absurd testament to the insupportable weight of exploitation. Kim’s crafted legs – Kim herself – cannot help this-Todd to walk not just because he doesn’t need her help but because he doesn’t need to walk. She has misunderstood entirely who he is – who all the men are, even though they try to communicate to her their desires and their philosophical investments, their immersion in ‘anthropology and autoethnography’ or ideas about ‘invisibility and cultural insensitivity’. When she quotes such exchanges, the story sardonically shows us how easy it is to pride oneself, falsely, for awareness, because while it sounds like Kim is ‘hearing’ them, she’s also revealing to readers what the Todds must resist in their endeavours to hold onto something like a self-generated identity. In a stunningly ironic reversal, ‘This Todd’ ends with Kim admitting that she sometimes ‘sleep[s] with the legs tucked next to [her] under the covers . . . pose[d] just so’. The prosthetic has overwhelmed the subject; when Kim tells Chelsea that she ‘just [has] to find the right fit’, she literalizes the way people are wrenched into conformity, made to approximate normative body types, and she demonstrates that what is appealing about the pretention of ‘get[ting] it’ – what is comforting, even arousing, about feeling oneself to be on the right side of history – can have more to do with staying in control (‘posed just so’) than with any direct confrontation with injustice. In fact, Kim seems to prefer to look at her men from behind. ‘When I picture this Todd’, she says early on with no trace of irony, ‘he is always seated with his back to me.’
Thomson-Spires, p. . Thomson-Spires, p. .
Thomson-Spires, p. . Thomson-Spires, p. .
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Thomson-Spires, p. . Thomson-Spires, p. .
Re-framing and Re-forming Disability and Literature
Impairment in Image and Word Bitter Medicine, a graphic memoir co-created by Canadian brothers Clem Martini and Olivier Martini (), charts a family’s decades-long battle with a health-care system undisposed to treat mental illness with compassion and adequate resources. The text was written by Clem, now an awardwinning playwright, with graphics and captions by Olivier (referred to as Liv throughout), the second of four sons to be diagnosed with schizophrenia. (Ben, the youngest, committed suicide not long after graduating from high school). Initially, Liv’s art seems primarily to accompany Clem’s narrative, which is a straightforward argument about the failings of mental health services that directly appeals to readers’ outrage – and to our agreement that the ‘problem’ of mental illness is as much caused as it is assuaged by the system. As the story progresses, though, the two accounts begin more often to diverge, and not inevitably to complement each other, so that we come to engage with companion renderings of a story that Clem and Liv have corresponding but not equivalent perceptions of. Indeed, Liv’s graphics sometimes actively interrupt or disregard what is happening in the prose. Something of an orderly method of reading and looking, of engaging with the ‘story’, gets exploded when text and graphic disagree, so that readers are not only reminded of the book’s co-creation but perhaps also confronted by expectations of authority they bring to reading in the first place – a need for authorial control, to put it more strongly, that might be heightened by the unease generated by psychiatric impairment. Formally, then, Bitter Medicine dramatizes the idea that no one version of these events, no single account of ‘madness’, can take priority – and maybe more acutely, that while there will always be multiple stories, even within a single family, that contradict or even impede each other, these divergent tales must all be taken seriously, because they help us to grasp the broader context that creates the meanings, distress, and possibilities inherent in schizophrenia. Without using the word, Bitter Medicine becomes a manifesto for neurodivergence, representing what might happen to notions of truth and reality when alternate modes of being and understanding unfold alongside each other.
Clem Martini and Olivier Martini, Bitter Medicine: A Graphic Memoir of Mental Illness (Calgary: Freehand Books, ). For more on the intersections of disability and memoir – including some resistance to the notion that selfhood must exist in linear narrative – as well as collaborative life-writing, see G. Thomas Couser, Recovering Bodies: Illness, Disability, and Life Writing (Madison: University of Wisconsin Press, ) and Vulnerable Subjects: Ethics and Life Writing (Ithaca: Cornell University Press,
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The indictment of this memoir is levelled most squarely against the incoherence of what Clem calls ‘Laissez-faire Health Care’, by which he refers to the discrepancy in care between psychiatric patients and those with ‘all other ailments’. After Canada’s ‘Great Closing’ of psychiatric facilities in the s – a programme meant to redirect federal funding from large, expensive mental health facilities towards a host of outpatient services – was derailed by a crushing recession, people who might have benefited from community integration were left to fend for themselves, without assistance from ‘workshops and clinics, . . . therapists and health care workers’. ‘Essential funding that was supposed to follow people with mental illness into the communities never did’, writes Clem, while on the facing page, one of Liv’s drawings shows a devilish figure (horns, tail, pitchfork), wearing a tie, with the caption ‘ .’ Other figures sit around a table: a committee determining the fate of deinstitutionalized patients? The Martini family? The latter is likely, given resemblances elsewhere, but the ambiguity is interesting: who’s in charge? In these two pages, the demonizing of madness collides with the disastrous economics of healthcare budgeting, and of course these are not unrelated. Stigma, a profound distrust of people with psychiatric impairments as diabolically at fault, held individually responsible for their situations – ‘’ ’, proclaims one lab-coat-sporting figure, pointing accusingly at another – conspires to create the ‘letting alone’ of psychiatric patients that, Clem argues, has ‘quite literally’ ‘beggar[ed]’ them. From here we arrive at the memoir’s centre, the ‘Five Circles of Hell’, a sequence of text and drawings that suggests that an inexorable decline in material conditions is practically guaranteed in a system that criminalizes mental illness, deprives individuals of access to jobs or housing, isolates people through the shunning mechanisms of prejudice, and withholds reasonable standards of care. Catherine Prendergast’s argument
); and James Overboe, ‘Ableist Limits on Self-Narration: The Concept of Personhood’, in Unfitting Stories: Narrative Approaches to Disease, Disability, and Trauma, ed. by Valerie Raoul and others (Waterloo, Ontario: Wilfred Laurier University Press, ), pp. –. Martini and Martini, p. . Martini and Martini, p. . Martini and Martini, pp. –. Martini and Martini, p. . Katherine Martyn and Annette Thompson write of the intense shame of mental illness: ‘as though you are the problem and your condition is a result of your actions’. The biomedical approach to triage, they argue, ‘fails to address the concerns of those with mental illness’. ‘The Metanarrative of Mental Illness: A Collaborative Autoethnography’, in The Metanarratives of Disability: Culture, Assumed Authority, and the Normative Social Order, ed. by David Bolt (New York: Routledge, ), pp. – (p. ). Martini and Martini, p. .
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that ‘insanity is a discursive construct’ is apt here; the identity of madness becomes ‘expressed, reinforced, and sometimes subverted by public discourse’, Prendergast writes, by ‘the discourse of experts, and by institutional structures’. Liv, coalescing in a single panel the socioeconomic vectors arising from the ‘repugnance’ associated with mental illness (Prendergast writes that ‘the mentally ill are the most reviled of the disabled’) puts it more bluntly: ‘’ ?’ Of course, the Martini memoir argues vehemently that what would be better would be an ethical distribution of services and resources and a way of responding to psychiatric conditions that honours the person, that seeks not to pacify but to ‘understand’. Bitter Medicine exemplifies what has been described as a kind of ‘mad methodology’. It encourages radical compassion for neurodivergence, and it renders the social, interrelational experience of schizophrenia in a way that challenges a singular, linear, evidentiary life story. Liv retains agency in these pages, tells his story, is a named co-creator, however much he has suffered in a system where ‘cutbacks’ lead to a ‘city wide bed shortage’ that might ‘leave someone experiencing a mental health crisis in a hallway, unsupervised for days’. Three days, in Liv’s case, untreated or cared for. ‘ ’, says Liv and Clem’s mother in one powerfully ironic and understated panel, while in another Liv asks two male figures (Orderlies? Security? Their squarish visored hats and ties make it difficult to tell) if he can ‘go outside’ – panels that emphasize the infantilizing, the neglect, the game-like nonchalance but also the punitive restrictiveness of the mental health system. Clem navigates these absurdities as Liv’s advocate and ascribes to his brother the boundary-protecting power of choice: ‘My brother and I are close. . . . That doesn’t mean that he shares everything with me . . . there are things that he keeps to himself.’ Where the hospital setting infiltrates a person, strips them of the dignity of an interiority that might have something to say about one’s own needs or preferences, it also bypasses
Catherine Prendergast, ‘On the Rhetorics of Mental Disability’, in Embodied Rhetorics: Disability in Language and Culture, ed. by James C. Wilson and Cynthia Lewiecki-Wilson (Carbondale: Southern Illinois University Press, ), pp. – (p. ). Prendergast, p. . Martini and Martini, p. . Martini and Martini, p. . Martini and Martini, p. . Martini and Martini, p. . Martini and Martini, p. . Martini and Martini, p. . Martini and Martini, p. . Martini and Martini, p. .
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them altogether, as if there is nothing ‘there’. This is why Bitter Medicine ends on three panels in which Liv chats with ‘ ’ he met at ‘ ’, why the last word of the book is Liv’s, and that word is ‘’: because even if there is no perfect, as Liv tells us, it matters that we are known, that we might exist in conversation with others, others who might grant confirmation of our imperfect realities. ‘Self help’, for all that the phrase smacks of a dangerously individualistic economy of progress, does also refer back to the services and resources that Liv, and his family, needed and benefited from when they were available. Helping oneself, in its most psychologically expansive guise, requires – encourages – our intimacy with others, and a robust ethics of care that allows us to remain, to be, the vibrantly disparate people we are.
Conclusion What does madness mean for memoir, a genre defined by the cohering presence of a rational narrator? Prendergast suggests that the ‘writing of schizophrenics can only be seen as arhetorical’, which is to say, limited in both scope and effect to mere ‘evidence’, proof of the very condition by which the subject has already been disqualified. Would not the form be practically nullified by a hallucinating, psychotic subject? By way of answering that question, which is fundamentally about the kinds of voices, characters, perspectives, and desires that literature will validate, I return to what the narrator Kim gets wrong about disability art in ‘This Todd’ – which is also what the story itself gets right. Kim reads her boyfriends through the same kind of delegitimizing scrim that might compel a person to eschew schizophrenic signification as rhetorically unmeaningful. Fetishizing her ‘legs’, Kim loses the rest of the person entirely, and construes her sculpture as supplying what is missing to the undifferentiated blank slate of lack, whereas the story portrays the various Todds as fully present characters whose differences from each other are integral to keeping the narrative in motion – forcing Kim to adapt her strategies, redirecting the artist as both speaker and sculptor, whatever her pretensions to recreating them in some idealized image. Like Nafissa Thompson-Spires, like Charles Bardes and Stephen Kuusisto and even Anne Holt, the Martini brothers in Bitter Medicine make space for a wide range of human types and forms; they invoke a broad continuum of bodymindedness on which conversation, something
Martini and Martini, p. .
Prendergast, p. .
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like reciprocity, between apparently antithetical subjects is possible. The ill, the strange, the asymmetrical, the dying: these tend to instigate a dramatic demand for explanation, the interpretive scramble that seeks to contain the threat of what seems atypical or unruly. But they are also emphatically ordinary aspects of life – life in which disease, disability, and ageing simply happen. The Todds, Bardes’s father, Clem Martini, Kuusisto’s lyric speakers – even Magnus Streng and Hanne Wilhelmsen – all disrupt the smooth ongoingness of life story defined in strictly normative terms, through conventional ideas about success, social value, beauty, agency, trustworthiness, or intelligence. But so too do they refuse to be confined, stabilized, or tamed by the texts, both ideological and literary, that feature them.
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Overcoming Decline (in) Narrative Episodicity in Stories of Dementia and Ageing Martina Zimmermann
Introduction Pessimism about ageing relates to a cultural narrative of decline that has shifted anxieties about growing old to younger and younger ages. This decline narrative extends to values of all kinds, including health and sexuality, friends and family, economic and social status, and, perhaps most of all, mental capabilities. The anticipated drama of potential dependency or vulnerability incurred with ageing is reinforced by a parallel narrative about successful ageing. This narrative prizes the independent, self-sufficient and vital self, and thrives in a culture that hails youth as embodying energy, potential, and hope. Culturally prescribed ageing is successful ageing, and any deviation from this narrative script, real or imagined, furthers negativity about progression on the temporal trajectory towards old age. What people overlook is that life as lived lacks a narrative arc or the coherence of plot that a life as narrated can display. This means that anxieties arise because, at midlife or even younger ages, successful ageing anticipates a narrative arc, which, in life as lived, remains to a certain degree beyond an individual’s control – and, in life as narrated, can only be fully appreciated from the perspective of its end point. Conceptually to break through this anxiety is hard to do, because Acknowledgements: This work was supported by a UK Research and Innovation Future Leaders Fellowship [MR/T/]. Margaret Morganroth Gullette, Declining to Decline: Cultural Combat and the Politics of the Midlife (Charlottesville: University Press of Virginia, ), p. . Wayne Booth, The Art of Growing Older: Writers on Living and Aging (; Chicago: The University of Chicago Press, ), pp. –; Gullette, p. . Mark Freeman, ‘“Even Amidst”: Rethinking Narrative Coherence’, in Beyond Narrative Coherence, ed. by Matti Hyvärinen and others (Amsterdam: John Benjamins, ), pp. – (p. ); Gullette, p. . Cheryl Mattingly, ‘Emergent Narratives’, in Narrative and the Cultural Construction of Illness and Healing, ed. by Cheryl Mattingly and Linda C. Garro (Berkeley: University of California Press, ), pp. – (pp. –).
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narrativity is an enduring concept across disciplines and sectors, including Literature and Medicine. This chapter explores how the culturally and medically prized concept of narrative influences pessimism about ageing. It takes three specific steps. First, it reviews seminal texts in Literature and Medicine to illustrate how signature characteristics of narrative dominate cultural and medical expectations of how people experience themselves and think about their lives. Second, taking dementia as a situation where anxieties about ageing and continuity of self are particularly acute, it illustrates the pressure emanating from narrativity for life as lived and life as narrated, revealing episodicity as a viable response to this two-fold pressure. Third, in looking at the life histories of older people, gathered by in-depth unstructured interviews and published in book format, this chapter demonstrates that episodicity is hugely relevant also for how older people retrospectively pitch their lives, suggesting that mid-life anxieties about living along a prescribed narrative arc into old age are perhaps exaggerated. Overall, this chapter argues that thinking about the episodic aspects of experience has the potential to help overcome pessimism about ageing, because it embraces the uncertainties of life as lived, while removing at least some of the pressure rooted in understanding life and ageing as if they were narrated.
Narrativity, Episodicity, Dementia, and Ageing In the field of Literature and Medicine, it has long been understood that practitioners take narrative as a means for obtaining access to subjective experience of illness, while believing that it enables the sick individual to articulate a changing sense of identity in a shifting world of experience. Such a narrative medicine approach considers narrative as therapeutic and rewarding for both parties. With the turn towards a narrative paradigm in
Arthur Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condition (New York: Basic Books, ); Howard Brody, Stories of Sickness, nd edn (New York: Oxford University Press, ). The first two paragraphs of this section expand on perspectives summarized by Angela Woods, in ‘The Limits of Narrative: Provocations for the Medical Humanities’, Medical Humanities, , (), –. Kathryn Montgomery Hunter, Doctors’ Stories: The Narrative Structure of Medical Knowledge (Princeton: Princeton University Press, ); Narrative Based Medicine: Dialogue and Discourse in Clinical Practice, ed. by Trisha Greenhalgh and Brian Hurwitz (London: BMJ Books, ); M. Faith McLellan and Anne Hudson Jones, ‘Why Literature and Medicine’, Lancet, , (), – (p. ); Femi Oyebode, preface to Mindreadings: Literature and Psychiatry, ed. by Femi Oyebode (London: RCPsych Publications, ), pp. vii–ix; and, more recently, Trisha Greenhalgh, Cultural Contexts of Health: The Use of Narrative Research in the Health Sector (Copenhagen: World Health Organization Office for Europe, ), pp. –.
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social sciences and medical practice, however, a high level of narrative articulacy became an essential criterion for a productive encounter between practitioner and patient. Normative claims include aspects of narrative performance and form, the assumption being that narrative construction of meaning is part of how people experience their lives. In addition, particular prototypes or myth-like versions of an illness experience fashion the narrator as survivor of their condition, effectively restituted to their former life. Deemed indicative of an individual’s ability successfully to deal with a condition, such triumphalist ‘resilience’ narratives, however, pressure patients to ‘rise above their suffering, battle their disease, and believe that everything will be fine in the end’. But the concept of narrativity has not remained unchallenged. Philosopher Galen Strawson advocates a concept of self-experience, where one is aware that one ‘has long-term continuity’, but one does not perceive of oneself as an entity persisting through time, instead experiencing one’s life in episodes (although these episodes are still mini forms of narrative). In a similar vein, philosopher Crispin Sartwell has argued against an increased ‘obsession with language’, which involves narrative explaining time, value, and human identity and pitching life as a ‘teleological project’. Psychologist Mark Freeman agrees with Sartwell that, in its normative focus on organization, order, and coherence, narrative can be oppressive. Among these aspects, narrative theorist Matti Hyvärinen and colleagues identify the mission to find value in coherence most problematic. According to this coherence paradigm, narratives proceed in
Rita Charon, Narrative Medicine: Honoring the Stories of Illness (New York: Oxford University Press, ); Ivor F. Goodson and Scherto R. Gill, ‘The Narrative Turn in Social Research’, Counterpoints, (), –. Arthur Frank, The Wounded Storyteller: Body, Illness, and Ethics (Chicago: University of Chicago Press, ); Anne Hunsaker Hawkins, Reconstructing Illness: Studies in Pathography, nd edn (West Lafayette: Purdue University Press, ); for a critical review, see Neil Vickers, ‘Illness Narratives’, in A History of English Autobiography, ed. by Adam Smyth (New York: Cambridge University Press, ), pp. –. Barbara Ehrenreich, Smile or Die: How Positive Thinking Fooled America and the World (London: Granta, ); Kathlyn Conway, Illness and the Limits of Expression (Ann Arbor: University of Michigan Press, ), p. . Galen Strawson, ‘Against Narrativity’, Ratio, , (), –. I owe thanks to Brian Hurwitz for sharing the observation that Strawson’s episodicity has not expunged narrativity from selfunderstanding. Crispin Sartwell, End of Story: Toward an Annihilation of Language and History (Albany: State University of New York Press, ), p. . Mark Freeman, ‘Beyond Narrative: Dementia’s Tragic Promise’, in Health, Illness and Culture: Broken Narratives, ed. by Lars-Christer Hydén and Jens Brockmeier (New York: Routledge, ), pp. – (p. ).
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a linear, chronological way towards a thematic closure, and life is deemed better and healthier, if the life story and identity told are coherent. These convictions have bolstered a critical turn in narrative research. Sociologist Mike Bury has influentially argued that ‘links between chronic illness and self-identity’ should not be assumed as a given, because different levels of experience and related verbal expression need to be distinguished. Likewise, sociologist Francesca Polletta has pointed out that stories are also ‘social performances that are interactively constructed, institutionally regulated, and assessed by their audiences in relation to hierarchies of discursive credibility’. Reviewing these issues from the vantage point of the medical humanities, Angela Woods has encouraged a more critical reflection on the position and limits of narrative in framing human experience. Taking stock from these critical perspectives, Sara Wasson has suggested a reading practice that focuses less on narrative coherence and more on the ‘value of textual fragments, episodes and moments considered outside a narrative framework’. I pursue such a reading practice in this chapter, as I seek to break through negative perceptions of ageing resulting from the idea that identity and personhood are narratively constructed. This goal in mind, this chapter first takes a closer look at dementia. The link between dementia and ageing is both medical and cultural. Next to cancer and cardiovascular conditions, neurodegenerative disorders are the most common conditions typical of old age, with Alzheimer’s disease the most prevalent form of dementia in older people. Concurrently, the condition’s unidirectional disease trajectory resonates with concepts of
Matti Hyvärinen and others, ‘Beyond Narrative Coherence: An Introduction’, in Beyond Narrative Coherence, ed. by Hyvärinen and others, pp. – (pp. , ). Mike Bury, ‘Illness Narratives: Fact or Fiction?’, Sociology of Health and Illness, , (), – (pp. , ). Francesca Polletta and others, ‘The Sociology of Storytelling’, Annual Review of Sociology, (), – (p. ). Woods, p. ; see also Rebecca A. Bitenc, Reconsidering Dementia Narratives: Empathy, Identity and Care (Abingdon: Routledge, ), pp. –. Sara Wasson, ‘Before Narrative: Episodic Reading and Representation of Chronic Pain’, Medical Humanities, , (), – (p. ). Consider, e.g., Jerome Bruner, Making Stories: Law, Literature, Life (Cambridge, MA: Harvard University Press, ); Paul John Eakin, How Our Lives Become Stories: Making Selves (Ithaca: Cornell University Press, ); Paul John Eakin, Living Autobiographically: How We Create Identity in Narrative (Ithaca: Cornell University Press, ). Martin Prince and others, World Alzheimer Report (London: Alzheimer’s Disease International, ).
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decline and loss that the popular imagination connects to ageing. I here take dementia as epitomizing ageing anxieties with particular acuteness, while threatening an individual’s narrative competency and sense of autobiographical continuity. Reading Wendy Mitchell’s Somebody I Used to Know (), I explore where narrativity as compared to episodicity positions dementia – writing about it as much as the experience itself. My reading will show that it is challenging to overcome the persuasion that narrative is both constitutive of personhood and central to communicating identity. Still, I argue, episodic strategies are able to expand narrative, locating personhood in short-lived moments of experience, not drawn-out temporal trajectories. Having established this, the chapter moves to thinking through the implications for ageing more generally of such an episodicity-influenced narrative approach. Book-published life-writing on ageing that does not gain its thrust from illness is rare. Therefore, I will examine a different literary genre, considering oral histories collected in Swiss writer Susanna Schwager’s Das volle Leben: Frauen u¨ber achtzig erzählen [The Full Life: Women over Eighty Narrate]. Mindful that oral history taking has long been struggling with the normative concept of narrative, episodic emphasis in these histories is significant. Although narrating towards the near-end of their lives (i.e. from a position when articulating a narrative arc becomes a real possibility), the interviewees focus on few important moments that shaped their lives. This suggests that a stronger focus on episodic self-experience throughout life has the potential to challenge concepts of degeneration and decline as core determinants of the ageing narrative.
Gullette; Norm O’Rourke, ‘Alzheimer’s Disease as a Metaphor for Contemporary Fears of Aging’, Journal of the American Geriatrics Society, , (), –; Eva-Marie Kessler and others, ‘Dementia Worry: A Psychological Examination of an Unexplored Phenomenon’, European Journal of Ageing, , (), – (p. ); Martina Zimmermann, The Diseased Brain and the Failing Mind: Dementia in Science, Medicine and Literature of the Long Twentieth Century (London: Bloomsbury, ), p. . Wendy Mitchell with Anna Wharton, Somebody I Used to Know (London: Bloomsbury, ); all references to this edition incorporated in the text. On ‘latent coherence’, see Freeman, ‘Even Amidst’, p. . Bitenc takes a similar ‘moderate or qualified narrativist approach’ (p. ). Susanna Schwager, Das volle Leben: Frauen u¨ber achtzig erzählen (; Munich: Piper, ); all references to this edition are my own translations and incorporated in the text. Goodson and Gill, pp. , .
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Episodic Experience, Narrative Articulation: Coherence in Book-Published Accounts of Dementia Wendy Mitchell was diagnosed with dementia at the age of fifty-eight. Any health diagnosis in mid-life potentially endangers successful ageing, but few alter a person’s outlook and affect their perception of lifetime continuity more than dementia. Mitchell’s articulation of the diagnostic impact is piercing. Life before dementia ‘wasn’t fuzzy around the edges . . .; it was pin-sharp’ (p. ). With dementia, life has become ‘exhausting in a way it never was before’ (p. ). As a person with young-onset dementia, Mitchell belongs to a group of individuals particularly vocal in its desire to be heard in conversations about continued agency and care provision. Publishing Somebody I Used to Know attests to this desire, but, like most illness narratives, it equally attempts to ‘restore to reality its lost coherence and to discover, or create, a meaning that can bind it together again’. Mitchell offers a highly articulate account with a clear narrative arc. This comes against the understanding that dementia’s chronic degenerative disease progression impacts on the cognitive abilities required to tell a coherent narrative. Such mainstream ideas about people with dementia, in fact, have informed doubts about an individual’s diagnosis, as and when they publish their books, Mitchell herself having been exposed to such criticism. These kinds of doubts remain rooted in a focus on language breakdown and loss of semantic knowledge, seen in linguistic research during the s and s, although comparatively recent sociolinguistic interventions have challenged the merit of external validation of the narratives told by people with dementia, for example furthering strategies
Michael Bury, ‘Chronic Illness as Biographical Disruption’, Sociology of Health and Illness, , (), –; G. Thomas Couser, Recovering Bodies: Illness, Disability, and Life Writing (Madison: University of Wisconsin Press, ), pp. , ; Shlomith Rimmon-Kenan, ‘The Story of “I”: Illness and Narrative Identity’, Narrative, , (), –; Thierry Jutel and Annemarie Jutel, ‘“Deal with It. Name It”: The Diagnostic Moment in Film’, Medical Humanities, , (), –. Martina Zimmermann, The Poetics and Politics of Alzheimer’s Disease Life-Writing (Basingstoke: Palgrave, ), pp. –. Accounts of people with dementia are usually by young-onset individuals. People with dementia have published since , but to the present day their key concern remains recognition of their continued personhood, identity, and self even as their capabilities to narrate change. Hunsaker Hawkins, p. . Peter J. Whitehouse, ‘Losing My Mind: An Intimate Look at Life with Alzheimer’s’, New England Journal of Medicine, , (), ; Wendy Mitchell with Anna Wharton, What I Wish People Knew about Dementia: From Someone Who Knows (London: Bloomsbury, ), pp. –.
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of collaborative storytelling. Mitchell’s choice to work with a professional writer confirms the value assigned to narrative order and coherence. It is therefore significant that, on an aesthetic level, Mitchell confronts disruption of her autobiographical self, including notions of breakdown. This is perhaps not surprising, given that fragmentation and disruption have become signature narrative tactics in literary accounts of dementia, indicative of the perception that dementia challenges coherence and continuity. In italicized paragraphs, Mitchell talks to her former self in the second person, reflecting on capabilities she no longer has – things that ‘would be impossible for me, but . . . were nothing to you’ (p. ). The strategy of letting ‘this new me’ (p. ) speak to the ‘old Wendy’ (p. ) – old here meaning the former, young(er) Wendy – can be understood as Mitchell’s way to hold on to acquired capabilities for as long as possible. But the contrasts emerging from these alternating passages document Mitchell’s sense of loss (p. ), their rendering in narrative suggesting how this loss is experienced as a break in continuity. But dementia does not only challenge the connection between past and present. Confirming Freeman’s concept of ‘narrative foreclosure’, Mitchell senses that dementia also steals the future (p. ). Narrative foreclosure has been identified as the conviction that one’s future does not hold new opportunities that are able to ‘change one’s life-story’. It operates as a ‘function of individuals having internalized cultural narratives of decline’, and breaking the ‘coercive spell’ of such narratives can be particularly challenging for people with dementia, once language and narration reach their limit. As a consequence, Mitchell is invested in demonstrating that
Vai Ramanathan, Alzheimer Discourse: Some Sociolinguistic Dimensions (Mahwah: Lawrence Erlbaum Associates, ), pp. –; Athena H. McLean, ‘Coherence without Facticity in Dementia’, in Thinking about Dementia: Culture, Loss, and the Anthropology of Senility, ed. by Annette Leibing and Lawrence Cohen (New Brunswick: Rutgers University Press, ), pp. –; Lars-Christer Hydén, ‘Narrative Collaboration and Scaffolding in Dementia’, Journal of Aging Studies, , (), –; Matti Hyvärinen and Ryoko Watanabe, ‘Dementia, Positioning and the Narrative Self’, Style, , (), –. Dementia narratives, both fiction and life-writing, rely on fragmentation, for example interspersing a temporally continuous account with chapters on scientific perspectives on dementia, or with sections, in different typeset, offering the views of the narrated-about. See, e.g., Irmela Marei Kru¨ger-Fu¨rhoff, ‘Narrating the Limits of Narration: Alzheimer’s Disease in Contemporary Literary Texts’, in Popularizing Dementia: Public Expressions and Representations of Forgetfulness, ed. by Aagje Swinnen and Mark Schweda (Bielefeld: Transcript, ), pp. –; Martina Zimmermann, ‘“Journeys” in the Life-Writing of Adult-Child Dementia Caregivers’, Journal of Medical Humanities, , (), – (p. ); Zimmermann, Poetics, pp. –, –. E. T. Bohlmeijer and others, ‘Narrative Foreclosure in Later Life: Preliminary Considerations for a New Sensitizing Concept’, Journal of Aging Studies, , (), – (p. ). Mark Freeman, ‘Narrative Foreclosure in Later Life: Possibilities and Limits’, in Storying Later Life: Issues, Investigations, and Interventions in Narrative Gerontology, ed. by Gary Kenyon, Ernst
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the condition ‘has a beginning and a middle, as well as an end’ (p. ). Countering the narrative arc of the disease, she refuses the sick-role (p. ), instead creating a role she identifies as lacking in the care pathway: helping people understand the disease better, and explaining that ‘I was still me. Still me, but with a diseased brain’ (p. ). Mitchell becomes an ambassador for people with dementia, her life turning ‘busier now, more varied and challenging than it ever was when I was at work, just in different ways’ (p. ). In line with these activities, publishing a second book, What I Wish People Knew about Dementia: From Someone Who Knows (), addressed to formal and informal carers, is both product and reflection of Mitchell’s new-found continuity. This new-found continuity extends to Mitchell’s perception of herself and her approach to daily life. It goes without saying that, to a significant extent, Mitchell’s sense of loss is embedded in the gravitational pull of autobiographical memory, the idea that ‘memories make us who we are’. Her effort to create what she terms a ‘memory room’, in which ‘dementia isn’t winning’ (p. ), underlines the importance of memory for a sense of continuity inherent in the autobiographical self: It is the present that brings me here, but it is from the past that it has been created, a tapestry of my life, and all its wonderful people and places. One foot inside this room grants me my history. In a second I can feel like a child again, or a new mother, a single mum, or a proud one when I glance at my girls’ graduation photos.
This description really echoes Strawson’s take on an episodic existence. Rather than adding up to a coherent, ‘almost inevitably falsifying narrative’, an episodic existence comes down to ‘an assorted basketful of understandings’, where the past informs the present ‘without being present or alive as the past’. With reference to Strawson’s perspective, Naomi Kru¨ger describes dementia as ‘by nature an associative, episodic, momentary existence’. Mitchell lives in episodic terms. She emphasizes how important it is for her ‘not to think further than today’ (pp. , ), an
Bohlmeijer, and William L. Randall (Oxford: Oxford University Press, ), pp. – (pp. , ); see also Frank, p. . See also Mitchell with Wharton, What I Wish, pp. , , , . Mitchell with Wharton, What I Wish, p. . Mitchell with Wharton, What I Wish, pp. –. Stawson, pp. , (emphasis original). Naomi Kru¨ger, ‘The “Terrifying Question Mark”: Dementia, Fiction, and the Possibilities of Narrative’, in Popularizing Dementia: Public Expressions and Representations of Forgetfulness, ed. by Aagje Swinnen and Mark Schweda (Bielefeld: Transcript, ), pp. – (p. ).
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attitude beautifully conveyed by the present tense of the roman sections in Somebody I Used to Know. Confirming that this outlook assumes more urgency as time passes and cognitive capabilities change, Mitchell’s second book does no longer play with expectations of narrative coherence as previously expressed in italicized sections. What I Wish People Knew about Dementia is arranged thematically rather than chronologically, but still projects emotional coherence, since it expressly focuses on Mitchell’s concerns about care for people with dementia. Coherence in her episodic existence additionally derives from how Mitchell’s second book aligns with her presence on the Twitter messaging platform. A recent report suggests that people with dementia use Twitter to ‘construct . . . personal identities . . . by documenting their personal experiences’. Mitchell’s identity construction derives from collecting episodic memories in blog format, but also from political activism, since Twitter ‘gives [her] a voice and . . . can change minds’. This strategy echoes the choice by some people with dementia to publish in essay format – the narrative form circumventing issues of decline while enabling focus on particular moments of lived experience. Forms of representing illness enabled by online platforms have been identified as ‘welcome alternatives to structure, coherence and unity’ typical of the dominant literary form of illness narratives, because they advance an ‘episodic storytelling’, where the story told unfolds in ‘small chunks’ and over a longer period of time. Stella Bolaki, who studies illness narratives that challenge linearity and coherence, finds that micro-blogs like Twitter encourage the kind of ‘emergent narratives’ that anthropologist Cheryl Mattingly describes as embodied and improvised. In this regard, the form imposed by Twitter resonates with Mitchell’s actual daily life, where the present becomes divided into small units of experience, as she goes through ‘shortlived moments of grief, followed quickly by extreme highs of happy memories’. If it is true that episodic emphasis in dementia narratives supports the experiential world of people with cognitive impairment, similar emphasis
Mitchell with Wharton, What I Wish, pp. , ; Bitenc, p. . Catherine V. Talbot and others, ‘How People with Dementia Use Twitter: A Qualitative Analysis’, Computers in Human Behavior, (), – (p. ). Mitchell with Wharton, What I Wish, pp. , . Zimmermann, Poetics, pp. –, –. Stella Bolaki, Illness as Many Narratives: Arts, Medicine and Culture (Edinburgh: Edinburgh University Press, ), p. ; Talbot and others, p. . Bolaki, pp. , ; Mattingly, pp. –. Mitchell with Wharton, What I Wish, p. .
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may well prove productive in the context of ageing per se, given its strong connotations of decline. Mattingly developed the concept of ‘emergent narratives’ in relation to oral narratives encountered in the clinical context. These narratives are comparable to what Hyvärinen and colleagues term ‘“naturally occurring”, oral narratives’ and witness experientiality much more obviously than narratives that follow a chronological order. In the next section, I will draw out manifestations of episodicity in the oral histories of older women to illustrate that retrospective lifetime continuity may well do without chronological coherence – in favour of a focus on particular moments and experiences, where notions of decline remain near absent.
Ageing and Episodicity: Against a Narrative of Decline The temporal aspect of narrative, especially its ‘progressive movement towards an ending’ expresses somatic ageing. Mitchell herself lives this narrative, writing: ‘I don’t want to see the change that’s occurring in me . . . I didn’t speak the way I used to speak, I didn’t look how I remembered, and I know that as I age it will only get worse’ (p. ). Ageing entails experiences of degeneration, decline, and loss. Whether these experiences primarily connect to the biological reality of senescence is beyond the scope of this chapter. What I am interested in here is that the imposition of a linear and chronological narrative arc, with its obligation to order and coherence, privileges a storying of the passing of time. ‘Vectored time’ (a term used by Rita Charon), then, connects to what Helen Small describes as the experience of lessening opportunities, as time and life run out. The ‘rediscovery of narrative as an essential form of seeking and representing knowledge’ has significantly shaped how gerontological endeavours have attempted to understand the search for meaning and identity in relation to ageing. But life does not have the ‘forward thrust’ of narrative;
Heike Hartung, Ageing, Gender and Illness in Anglophone Literature: Narrating Age in the Bildungsroman (Abingdon: Routledge, ), p. . Charon, p. ; Helen Small, The Long Life (Oxford: Oxford University Press, ), p. . Thomas R. Cole and Ruth E. Ray, ‘The Humanistic Study of Aging Past and Present, or Why Gerontology Still Needs Interpretive Inquiry’, in A Guide to Humanistic Studies in Aging: What Does It Mean to Grow Old?, ed. by Thomas R. Cole, Ruth E. Ray, and Robert Kastenbaum (Baltimore: Johns Hopkins University Press, ), pp. – (p. ); see also Margaret Cruikshank, Learning to Be Old: Gender, Culture, and Aging, rd edn (Lanham: Rowman & Littlefield, ), pp. –.
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it is uncertain and fragmented. Therefore, Freeman holds, ‘the resultant stories ought to be messy in turn’. Oral life histories appear particularly suitable for this enquiry, although shifting genre might incur the danger of ‘collaps[ing] distinctions between different narrative forms and contexts’. I expressly read oral histories published in book form here, because they enable two pursuits: considering oral narratives in a form obliged to literariness and interrogating the import of narrativity in a context where narrative is both the ‘method of enquiry’ and the phenomenon under scrutiny. As mentioned in the introduction, my design is not to provide an aesthetic analysis that seeks out a narrative arc. Following Wasson’s example, I try to pursue an episodic reading, where I remain concerned with the significance of textual fragments and episodes, while staying attuned to the wider social and cultural context from which these accounts emerge. Oral history taking is defined as a practice of recording but also as preserving testimony. However, when it comes to publishing, narrativity directs editorial practices. Susanna Schwager conducted open-ended interviews with twelve Swiss women over eighty, simply following ‘a good conversation’ (p. ). Reflecting on her method of working, Schwager stresses that she stays true to the spoken word, following audio recordings as closely as possible. But in doing so, she explains, ‘I cut up, choose, put together . . . I weave a narrative thread [Erzählfaden] into the monologue, which had not existed in the free and unstructured conversations.’ Schwager’s strategy, once again, evidences the cultural dominance of narrativity. It is, thus, all the more significant (since revealing a certain editorial compulsion to impose a narrative arc) that not a single woman interviewed relies on a chronological rendering of her life. They confirm Helen Small’s point that certain events only matter during specific phases in life, losing, on looking back on the full life lived, their relevance and importance. Most consider the influence of their parents, reflect on the
Hannah Zeilig, ‘The Critical Use of Narratives and Literature in Gerontology’, International Journal of Aging and Later Life, , (), – (p. ); see also Mattingly, pp. –. Freeman, ‘Even Amidst’, p. . Woods, p. . Goodson and Gill, p. . Wasson, p. . ‘Principles and Best Practice for Oral History’, Oral History Association, October [accessed March ]. Susanna Schwager, Das volle Leben: Männer u¨ber achtzig erzählen [The Full Life: Men over Eighty Narrate] (; Munich: Piper, ), p. . Considering aspects of gender goes beyond the scope of this chapter; suffice to say that Schwager introduces five women as ‘mother’ or ‘housewife’, but none of her eleven male interviewees as ‘father’. Small, p. .
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opportunities (or not) afforded by school, and, at least in passing, mention the impact of the Second World War. But across boundaries of class, they zero in on what enduringly shaped them. Introduced by Schwager as ‘gipsy, housewife, mother’, Urselina Gemperle almost exclusively lingers on the fact that a Swiss children’s organization had taken her away from her mother after the father’s death (pp. –). This was a highly influential experience for her, because her own children had similarly been taken away from her (p. ). The argument could now run that Gemperle’s limited opportunities early in life impact on the narrative complexity of her late-life reflections, but the account of singer and entrepreneur Lys Assia confirms my observation that these life stories remain focused on a few significant events. Assia, who won the Grand Prix d’Eurovision de la Chanson in , tells a success story in showbusiness, but over half of her account mulls over her husband’s early death and a break-in where she incurred injuries from which she recovered only slowly. As a third example, midwife Marie Zu¨rcher talks about the enormous satisfaction of her work (p. ). Taking her interlocutor at her word, Zu¨rcher explains that her ‘life consists of thousands of stories. Happy and sad ones’ (p. ). Finding that ‘coming into this world’ is ‘a battle, much suffering and also much joy’ (p. ), her stories revolve around life and death, including women’s choices in the face of unwanted pregnancies. Mark Freeman would find these life histories much less ‘coercive and controlling’ than the kind of narratives critics of narrativity have become concerned with. This is at least partly explained by the fact that the lifetime identities evinced from these stories are a kind of identity that Freeman locates in the living moment of the present. An identity less borne out of an individual’s history, but rather out of her being as such, ‘out of those less particularized dimensions of history that become sedimented in the form of our interests, inclinations, and passions’. And these result from specific moments or events, not a meticulous chronological trajectory. Time per se is worth considering in these histories because it helps appreciate the importance of foreclosure for the experiential world of the women interviewed. Margaret Cruikshank’s observation that late life is the only period in life when individuals have ‘ample free time’ is relevant here. The haste with which individuals move from one experience and task to the next, which the age scholar connects to a young age, links into the kind of narrative continuity that Sartwell laments. Sartwell shows himself
Freeman, ‘Beyond Narrative’, pp. , .
Cruikshank, pp. , .
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concerned about the need for meaning as a ‘pressure, an anxiety and furthermore as the project of having some project, and hence as a project that can never be discharged’. Commenting on Sartwell, Freeman wonders whether ‘moving beyond narrative, beyond the confines of storyline’ one could experience ‘something like liberation’. Politician Emilie Liebherr, also interviewed by Schwager, closes her account in precisely this spirit: ‘Now I am old and I am free again’ (p. ). That freedom from time pressure is liberating echoes Mitchell’s perception. Dementia, she explains, affords her ‘contentment in the moment’, because she finds herself ‘stripped of the same pressures that others are under; an escape from the hamster wheel of life that people are still desperately spinning on’. When the ‘unfolding of time’ is not experienced in ‘normative patterns of progression’, Lisa Baraitser discusses, meaning does not (any longer) reveal itself in a linear narrative, through the passing of time. Like the women who have surpassed their eightieth year, Mitchell feels that people with dementia ‘no longer have that pressure of a future’. Towards the end of their lives, the pressure to comply with a narrative arc begins to lift – a pressure that Mitchell, in mid-life, still feels. Instead of surrendering to the cultural pressures of narrativity, the women interviewed focus on a few key moments and events, suggesting that younger age overrates the importance of a narrative arc.
Conclusion The women interviewed by Schwager are not representative, although they belong to different social classes. None of them lingers on perceived failures or despair about their experiences. Rather, they look back on life with a certain degree of contentment and fulfilment, sharing a sense that their life had meaning and that they are able to accept death as the end point of that life. As such, they are able to tell a narrative that is
Sartwell, p. . Freeman, ‘Beyond Narrative’, p. . Mitchell with Wharton, What I Wish, p. . Lisa Baraitser, Enduring Time (; London: Bloomsbury, ), p. . Mitchell with Wharton, What I Wish, p. ; see also Martina Zimmermann, ‘Terry Pratchett’s Living with Alzheimer’s as a Case Study in Late-Life Creativity’, in Creativity in Later Life: Beyond Late Style, ed. by David Amigoni and Gordon McMullan (Abingdon: Routledge, ), pp. – (p. ). On life review in the context of empirical research, see Thijs Tromp, ‘Older Adults in Search of New Stories: Measuring the Effects of Life Review on Coherence and Integration in Autobiographical Narratives’, in Storying Later Life: Issues, Investigations, and Interventions in Narrative Gerontology, ed. by Gary Kenyon, Ernst Bohlmeijer, and William L. Randall (Oxford: Oxford University Press, ), pp. – (pp. –).
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emotionally, thematically, and experientially coherent. In a similar vein, Mitchell is not representative of people with dementia, most of whom are less vocal and diagnosed much later in life. People with dementia have to cope with disruption to their autobiographical self by way of a diagnosis, but also by way of the condition’s impact on memory and the capability to narrate. The strategies pursued in the face of such challenge point to the enormous pressure imposed by narrativity – albeit to a lesser degree a pressure experienced by most people. I have looked at Wendy Mitchell’s experience in this analysis, because dementia at mid-life highlights with particular acuteness how narrativity informs anxieties about lifetime continuity at middle age. Reading oral histories of people over eighty in this context is instructive because it reveals that, even from the vantage point of nearly having reached the actual end of life, narrativity is much less important than is assumed around middle age. Mainstream concepts ignore any idea of identity that is not anchored in autobiographical memory and autobiographical time. Narrative is taken as constitutive of personhood and essential for articulating identity; and where narrative competence is at stake, the practitioner, much like the reader of literature, will still be compelled to listen for narrative. But a looser concept of narrative might be in order. As Helen Small puts it, if there is severe loss of capacity, we may do better to reject the narrative view altogether. That is, we may find it kinder and more in keeping with the person’s ability to give shape to their own life, to place much less emphasis on narrative, preserving it only weakly, as a dotted line to indicate the fact of an ongoing life, but faded powers of self-direction.
But this is not unproblematic in cultural contexts like the prosperous West, where fragmentation is taken as expression of memory loss and breakdown of language, since this also informs approaches to care. Both texts discussed in this chapter reflect such cultural contexts. Literary scholarship has pointed to differences between the American ‘improved
See also Bitenc, p. . Jens Brockmeier, ‘Questions of Meaning: Memory, Dementia, and the Postautobiographical Perspective’, in Beyond Loss: Dementia, Identity, Personhood, ed. by Lars-Christer Hydén, Hilde Lindemann, and Jens Brockmeier (New York: Oxford University Press, ), pp. – (p. ); see also Eakin, How Our Lives, p. . Wasson, p. ; Claire Charlotte McKechnie, ‘Anxieties of Communication: The Limits of Narrative in the Medical Humanities’, Medical Humanities, , (), pp. – (p. ). Small, pp. –; see also Kru¨ger, pp. –. Kru¨ger-Fu¨rhoff, p. ; Susan M. Behuniak, ‘The Living Dead? The Construction of People with Alzheimer’s Disease as Zombies’, Ageing and Society, , (), pp. – (p. ).
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self’ and the British ‘ironic self’ in much illness life-writing. But Western cultures generally prize the independent self to an extent that has made it hard for people with dementia to assert their continued personhood, perhaps especially because of the value bestowed on narrative coherence and temporal continuity. That said, the kind of life in the ‘present moment’ articulated by Mitchell imposes itself less as ‘a moment in extended crisis’, as Lauren Berlant would say, or a ‘slow death’ where deterioration is the ‘defining condition of its experience and historical existence’. Rather, Mitchell’s approach invites thinking in episodic terms, indirectly validated by how older people recount their lives. Valuing a looser concept of narrative, which, through an emphasis on episodic experience, is able to hold moments of fragmentation and uncertainty, has the potential to enhance dementia care, because identity and personhood become less challenged. Advocating a mixed approach to reading dementia stories that acknowledges the cultural leverage of narrative, while recognizing the enabling powers of episodicity, this chapter hopes to have illustrated the benefits of such an approach for ageing more generally. A stronger focus on episodic self-experience throughout life has the potential to challenge aspects of the decline narrative that nourishes pessimism about ageing. It can rescue not only the demented self but also the ageing self.
Lisa Diedrich, Treatments: Language, Politics, and the Culture of Illness (Minneapolis: University of Minnesota Press, ), pp. –. Zimmermann, Diseased, pp. –. Lauren Berlant, Cruel Optimism (Durham: Duke University Press, ), pp. , ; see also Wasson, p. .
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Literature as a Form of Care? From Therapeutic Narratives to the Literature of Care Alexandre Gefen
One day we may know that there was no art, only medicine. Jean-Marie Le Clezio, Haï
The Birth of Therapeutic Literature In this chapter, I argue that the beginning of the twenty-first century marked the emergence of a way of writing and reading that I have termed ‘therapeutic’. By this, I mean a way of bringing literature and medicine closer together and extending a more general view on literary forms of attention and the ethics of care. I will start from the example of French and Francophone literature while suggesting that such a relational turn can be found in other languages and cultures. On a general level, it is useful to think of literature as a relationship – between the author and herself, between the author and her relatives, between the author and her readers, and between the readers themselves. It is also a means of producing awareness and attention, that is to say, to point out, to make visible, to give importance to people or to situations that society and the economy do not make visible. Everything happens, it seems to me, as if, in our democracies deprived of great collective hermeneutic and spiritual frameworks, literary narratives promise to consider the singular, to remember the dead, to give meaning to multiple identities by constituting cultural, sexual, professional, or other communities of affinity. The heroes of contemporary French fiction are often the sick or the bereaved, generally fragile individuals, those otherwise forgotten by history, communities ravaged by the injustices and discriminations of history. These discourses that can be understood as neo-humanist in their awareness of human dignity are part of what we usually call a return to literary ‘transitivity’:
I refer here to my essay, Réparer le monde. La littérature française face au XXIe siècle (Paris: Corti, ).
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they leave behind the aesthetic ideal of autonomy and self-reference and focus instead on thinking about material objects and issues, and they go against the grain of both managerial or mediatized storytelling and entertainment. This literature seeks to confront the world, to act, to remedy suffering, as well as to help us live our ordinary lives better. This forms a diffuse doctrine that we find as much in societal discourses about the uses of literature. This doctrine is often dramatized in narratives depicting reparative scenarios and also sometimes appears in the meta-discourse by writers about their own works. The subjects upon which the genre of what I call ‘remedial’ or therapeutic literature seeks to operate are multiple: wounded, written off, injured selves, or missing, enslaved, blinded communities; patchy, obscured, trivialized histories or stories and beings without language or representation. This can be seen in the way the contemporary French writer Régis Jauffret immerses himself in the life of a young martyred woman left sequestered in a cellar (Claustria, ) or in the way other writers come to speak of homeless or undocumented migrants despite their invisibility (Marie Darrieussecq, La mer à l’envers, or Éric Chauvier, Anthropologie, ). What is central among these questions is the topos of the suffering and dying body. It is important to underline, first of all, the sheer number of narratives of illness that exist in contemporary French and Francophone writing. While the idea that disease is ‘used’ in literature may be as old as humanism itself, the way in which contemporary French and Francophone writers seize directly, without the mediation of novelistic settings, upon the nosological and medical narration is something new.
HIV-AIDS Writing HIV-AIDS stories and novels written in the s – as political or collective acts in the United States and literary and intimate ones in France (exemplified by the meditations of Gilles Barbedette, the baroque, hedonistic, and ‘pop’ pornography of Guillaume Dustan, and the postmodern approach of Hervé Guibert) – have played an essential role in the formulation of this literary trend. This is because they constitute an
See my book L’Idée de littérature (Paris: Corti, ) and for the Anglo-Saxon world, Rita Felski, Uses of Literature (Hoboken: Wiley-Blackwell, ). On this opposition, see David Caron, ‘La littérature du sida’, Le Magazine littéraire, (December ), . I borrow the expression from Thomas Clerc, Preface, in Guillaume Dunstan, Œuvres I (Paris: POL, ), p. .
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accelerated transition between the formalist literature of the s and s and the socially responsible literature of the s and s. They led to hyperrealistic representations of the body and to a performative use of narration (many writers have claimed to feel better just through the act of writing itself ), while at the same time acutely questioning the conditions of our recourse to literature. Faced with a tragic disease that medicine was then unable to cure, the question of accompaniment, which was secondary before, became suddenly central to re-evaluating the potential healing role of narrative. The literary historian Stéphane Grisi extends this beyond the HIV-AIDS epidemic and adds to Hervé Guibert’s texts three other works from the end of the twenty-first century: those of Thomas Bernhard on his experience of tuberculosis, Fritz Zorn’s autobiographical account of cancer, and William Styron on his depression. Since the s, we can then think of the birth of the genre, autopathography. Its purpose, from a Freudian perspective, is ‘to accomplish the narcissistic restoration of the author’ and to ‘counterbalance the painful experience of inner splitting caused by the illness’. These stories all share a remedial ambition: ‘what seems to us to be quite new for about twenty years, is a certain recognition of the therapeutic virtue of writing without literary pretension, everyday writing, which asserts itself through stories that focus on the lived medical experience’, as Gérard Danou noted in . At the beginning of his study Anthropologie de la maladie, François Laplantine also identifies both new discourses, manifesting as ‘a beneficial model of perception of the disease’, and new textual forms, such as ‘the predominance in these autobiographies of the diaries of patients’ and ‘psychoanalytical novels’. These last examples are strongly marked by an understanding of the psychoanalytical cure that they duplicate in some way, as the narratives of Bernard Pingaud, Georges Perec, or Serge Doubrovsky exemplify. For these writers, it is not a question of interpreting, but rather of articulating their direct experience in the mode of a chronicle or a diary. In these texts, ‘if the disease is not always beneficial, as for the narrator of the Mots pour le dire [Marie Cardinal] who estimates
Stéphane Grisi, Dans l’intimité des maladies: de Montaigne à Hervé Guibert (Paris: Desclée de Brouwer, ), p. . The concept of autopathography was first proposed in by Anne Hunsaker Hawkins in her influential study Reconstructing Illness: Studies in Pathography (West Lafayette: Purdue University Press, ). Grisi, p. . Unless otherwise stated, all translations from the French are my own. Gérard Danou, Littérature et médecine ou les pouvoirs du récit, proceedings of the colloquium organized by the BPI (the Public Information Library) on and March in the Grande Salle of the Pompidou Centre in Paris (Paris: BPI/Centre Pompidou, ), pp. –. François Laplantine, Anthropologie de la maladie (Paris: Payot, ), p. .
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that “she” had “the luck to fall deeply in the disease” . . . it becomes nevertheless of vital significance for the one who makes the experience of it’, notes Laplantine. Aside from stories about ageing, which have been the subject of several studies, there is scant analysis in the French and Francophone context of the many other stories about illness which flourished in the expressive literature of the s and which have been popularized in writing produced by ordinary patients. The genre reached its peak in the s; as proof of this is the creation of the ‘Patients’ Words’ prize, which defines itself as ‘consecrating a new literary genre: the testimony on the disease as the main subject of a work’, insisting on the quality of style, the strength of the story, the depth of reflection, and the universality of the message transmitted. Some novels, such as Hôpital silence by Nicole Malinconi (who describes a hospital where she goes for an abortion as a place where ‘one is stripped of one’s own words’ and where one stands ‘as if deported’) or the magnificent diary of clinical self-observation by Alix Cléo Roubaud (–) – which was published after her death and not written with publication in mind – belong to the same distanced paradigm (a way of observing oneself from an anthropological viewpoint) as the Cytomégalovirus: Journal d’hospitalisation [Cytomegalovirus: A Hospitalization Diary] by Guibert. Many of them highlight not only the resilience of the writer, but a more or less nuanced evaluation of the disease, such as Valérie Dax’s Le cancer, c’est ma chance (). This philosophy is a reversal of the guilt-ridden discourse associated with illness that Susan Sontag studied in Illness as Metaphor, and in particular the war metaphors that accompany the fight against cancer. But, far from freeing cancer from the ‘fantasy of inescapable fatality’, these narratives only redouble it, in my opinion. Social and medical discourses esteem the usefulness of fighting the disease psychologically and recounting the story of one’s struggle against it. Here, the subject seems compelled to tell and to validate the disease that afflicts them, caught in the web of the argument according to which ‘the will to live is one of the major attributes of the
Laplantine, pp. –, note . See Martine Boyer-Weinmann, Vieillir dit-elle, une anthropologie littéraire de l’âge (Seyssel: Champ Vallon, ). See the website of the ‘Paroles de Patients’ prize [accessed August ]. Nicole Malinconi, Hôpital silence (Paris: Minuit, ), p. . See Susan Sontag, Illness as Metaphor and AIDS and Its Metaphors (New York: Doubleday, ). Sontag, p. .
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cure’, that Philippe Forest criticizes with vigour as part of his account of his daughter’s cancer (L’enfant éternel, ). Most contemporary testimonies, whether they are accounts of physical or psychological illness, are part of this tragic problem of empowerment. I see this in Se survivre, an account by Patrick Autréaux. The author, himself a doctor, tells the story of his chemotherapy. He alternates between a therapeutic struggle to ‘try to give the disease some amplitude, to get it out of oneself’ and unexpected epiphanies (when, after a painful examination, he starts to compose a poem to tell how ‘the whole world had just passed through him’). The writing is said to be born from the cancer (the patient presents his life as the realization of an annunciation: ‘“You will die young, you must write” a voice said to him’) and presents itself as a cure with metaphysical value: ‘I gave a sense to the huge aspiration which emerged: not to change or to become new, as I had believed, but to write differently – to write in order to cure what no one can cure us of.’ This literature of thaumaturgical monstration and combat aims to heal by staging the disease in an ultra-expressive way and tends towards forms of performance that the narratives of the HIV-AIDS era set up and which continue in original literary devices of psychological ‘intervention’. The Belgian writer Henry Bauchau, a psychoanalyst and novelist, transposed into a novel, L’Enfant bleu, published in , the therapy he undertook with an autistic child and, in a way, involved his readers through fiction into the workshop of art therapy. In a more indirect and discordant device, Olivia Rosenthal, confronted with Alzheimer’s disease, came to propose an eminently playful writing on this theme, whose playful formalism is reminiscent of the oblique strategies practised by someone like Perec or Roubaud in the face of misfortune. This literature of intervention and interaction finds striking examples in the works and literary devices of Mathieu Simonet, which are as much about writing as they are about investigations and literary performances. In La Maternité, a non-fictional narrative, Mathieu Simonet transforms the situation of being alongside the death of his mother (the model for which was undoubtedly given by Simone de Beauvoir’s Une mort très douce [A Very Easy Death] in ) into a choral narrative of the words of care expressed by the various intervening parties (including the psychiatrist Isabelle Blondiaux, herself
Philippe Forest, L’Enfant éternel: roman (Paris: Gallimard, coll. ‘Folio’, []), p. . Patrick Autréaux, Se survivre, et autres tableaux (Lagrasse: Verdier, ), p. . Autréaux, p. . Autréaux, p. . Autréaux, p. . Henry Bauchau, L’Enfant bleu: roman (Arles: Actes Sud, ).
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the author of a memoir entitled La lecture peut-elle soigner, Lecture et soins palliatifs (Can Reading Heal, Reading and Palliative Care)). The writer collects the speeches of ‘death professionals’, whom the author thanks, noting that he has ‘sometimes truncated the answers, to make this book a “literary object” and not a journalistic work’. In each case the disease feeds a narrative and literary inventiveness which seeks new forms to express unparalleled suffering. To these various presentations of disease, we must add the contemporary success of physician-writers like Martin Winckler. Although the character of the physician-writer has a long literary tradition, what is new is that Winckler writes as a doctor, not only to testify (the case is not isolated), but to relate his medical and literary practices. While Segalen at the beginning of the twentieth century makes ‘impassibility’ and ‘impartiality’ the values of the doctor, Winckler, as doctor-caregiver instead makes literary and medical empathy two analogous mechanisms: One becomes a doctor to heal suffering or symbolic pain . . . But that is also why I write. That’s why writing and caring have the same place in me. It is not enough to take care of people. It is also necessary to give an account of their lives, to bear witness to their struggles. Both care and writing have a lot to do with transmission. Obviously, my vocation is to repair and transmit, through care and writing. In caring, I extend my father’s desire to repair. In writing, I strive to understand what he secretly bequeathed to me, to free the words he buried in me, to pull them out of silence and oblivion.
This is how Martin Winckler sets up an analogy between writing and caregiving in En soignant, en écrivant [Healing and Writing]. His novel, La Maladie de Sachs [The Case of Doctor Sachs] has been translated into twelve languages and adapted for radio and film, proof – were it needed – of the success of the genre. The literary examples themselves reflect the contemporary medical practice of ‘narrative medicine’, which aims to ‘honour the stories of patients’ and to improve care. As such, ‘narrative medicine’ is based on
The memoir is unpublished, but Blondiaux is the author of La Lecture et ses variations thérapeutiques (Paris: Honoré Champion, ), which contains various overlaps. Mathieu Simonet, La Maternité: roman (Paris: Seuil, ), p. . See the bibliography of the ‘Group of Medical Writers’ on the GEM website [accessed February ]. Victor Segalen, Les Cliniciens ès lettres (Saint-Clément-la-Rivière: Fata Morgana, []), p. . Martin Winckler, En soignant, en écrivant (Montpellier: Indigène éditions, ), p. . See Rita Charon, Narrative Medicine: Honoring the Stories of Illness (New York: Oxford University Press, ).
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Literature as a Form of Care?
the attachment narrative therapies that emerged in the late s as an alternative to the Freudian therapies deemed to be guilt-ridden and deterministic, and which are now widely accepted. Some of these methods are simply ‘bibliotherapeutic’, but most are based on the externalization and ‘creative’ recapture of the individual history by the subject. The latter must strive to produce enriched and memorable narratives by attending to the ‘disparate’ and then ‘seeking to deconstruct single outcomes’. At the same time, the literary dimension is central to the illness narratives produced by doctors and caregivers who are themselves invited to workshops to read and produce subjective narratives.
Towards a Literary Ethics of Care More generally and apart from these situated literary practices in the doctor’s office or in the hospital, ‘taking care’ through literature is a central project of contemporary literature. Not only does literature come to describe the work of care, but care becomes the mission assigned to the author and the result of their work. The doxa of our time argues that literature allows not only to understand one’s own emotions, to be able to name them, but also to decode the sensitivity of others through reading and, as such, to get closer to them. Carole Talon-Hugon calls these moral theories ‘projectionist’ and Solange Chavel describes them as theories of the ‘moral imagination’. Literature, and in particular fiction, is supposed to create a ‘tunnel’ between oneself and others by allowing us to leave our own isolation. In its capacity to produce empathy, narratives are supposed to lead us to an affective displacement which is neither a distanced sympathy nor a transitory emotional contagion, and to offer us, by the mediation of a narrator onto whom we can project ourselves and our own situations, an initiation of empathy which enables a feeling of pity, especially. The role of culture in the broadest sense and of literature is to
See, for example, Janice Maidman Joshua and Donna DiMenna, Read Two Books and Let’s Talk Next Week: Using Bibliotherapy in Clinical Practice (New York: Wiley, ), which promotes the use of literature in the hospital setting in response to suffering as severe as domestic violence or sexual abuse. See Michael White and David Epston, Narrative Means to Therapeutic Ends (New York: Norton, ). Michael Payne, Narrative Therapy: An Introduction for Counsellors (London and Thousand Oaks: SAGE Publications, ), p. . Payne, p. . Carole Talon-Hugon, Morales de l’art (Paris: PUF, ), p. . Solange Chavel, Se mettre à la place d’autrui: l’imagination morale (Rennes: Presses universitaires de Rennes, ).
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offer us various forms of affective displacement, including in relation to ourselves. To encounter the suffering of others to recognize its legitimacy is to recognize ourselves affectively in others. This supposes not only the education of our sensibility, but a capacity of displacement of identity, a capacity in which artistic works, and in particular the narratives of fiction, are supposed to train us. Empathy is thus the form that care takes in literature, and the writer’s gesture of narrative attention is part of an ethics of care. This ethics of care has had important consequences in philosophy by imposing an ethic which focuses on actual and embodied situations, points of view, and voices; attitudes and feelings, rather than on general questions and abstract laws. Originating in the United States and in the feminist thought of the s, theories of care have found a field of application in all countries afflicted by neoliberalism which tends to erase non-commercial relationships. These have been particularly important in France, a country where family structures have been particularly affected by an individualistic turn in society and where urbanized lifestyles marginalize the most vulnerable. These most vulnerable are then entrusted to care workers in hospitals and nursing homes. Care, defined by Joan Tronto as ‘a generic activity that includes everything we do to maintain, perpetuate, and repair our “world” so that we can live in it as well as possible’, therefore manifests itself in literature in several dimensions. First, as thematic material which privileges the subaltern and the voiceless: unlike the traditional preoccupation of the novel for the ‘minuscules’ or the poor, it is a communicative inferiority that the writer attacks. This suggests that due to the recognition of autonomy within dependence, the theory of care is an asymmetrical moral theory, which does not suppose the complete exchange of positions nor their absolute resemblance, but a modification of the attention directed towards new questions and new subjects. Second, the distillation of the novel into a narrative: it is the ordinariness of distress and not the extraordinary that is aimed at, even in the painting of the catastrophe, which leads the narrative to a deliberately humble and anti-romantic art, or, at least, to issue a call for responsibility to the literary word.
Bernice Fisher and Joan C. Tronto, ‘Toward a Feminist Theory of Care’, in Circles of Care: Work and Identity in Women’s Lives, ed. by Emily K. Abel and Margaret K. Nelson (New York: State University of New York Press, ). See Pierre Michon, Vies minuscules (Paris: Gallimard, ), which was translated by Elizabeth Deshays and Jody Gladding as Small Lives (New York: Archipelago Press, ).
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Literature as a Form of Care?
Third, the absence of any abstract moral discourse: the discourse or metadiscourse of the writer does not propose the universalization of the case by exemplarity or theorization, but the activation of identification with restricted and subjective scope. From this point of view, the contemporary novelists propose not an ideology, but rather a micropolitics of sensibility. Such a demand cannot be assimilated to a predetermined project but is rather exercised in a situational and circumstantial manner. There are many examples of this attentive literature in the francophone world, thanks to the professional lives of some of its writers (Patrick Chamoiseau was a social worker, Gisèle Pineau, a nurse in a psychiatric hospital, Emile Ollivier, a sociocultural support worker for migrants in Quebec, Fatou Diome, a housekeeper in Dakar, to give just a few examples). In French literature, I can find no better example of this contemporary novelistic empathy that is at the heart of the form of care that literature can promise than Emmanuel Carrère’s story D’autres vies que la mienne [Other Lives But Mine], a bestselling work that portrays many forms of vulnerability and many places and situations of care, starting with the typical example of dependency and hospital care. The writer analyses with finesse the disability and the relational de-structuring that dependence entails. It is a sober text which refuses to employ ‘tear-jerkers’ and is accompanied by a very particular form of sentimental dryness, as exemplified by the character of whom we are told that ‘she received her disability card a few days before her eighteenth birthday’. Elsewhere, Carrère describes the daily life of the nurses and the team attending to a patient in palliative care, demonstrating penetrating acuity in the analysis of medicinal and psychological protocols as well as the complex relationships between the dying person and those who surround him. Individual portraits emerge, such as that of Patrice, whose ability to be present allows him to be there for the pre-programmed agony of a victim of Hodgkin’s disease: ‘His task would be to take care of her, to help her, to carry her, as from the beginning he carried her’. Or to empathize with a stranger at the morgue ‘in pink Bermuda shorts, chubby, lisping [who visits] voluntarily, on Sundays, to apply blush to corpses by guiding the fingers of their closest relatives over their faces’, ‘perhaps simply’ guided by ‘the taste of rendering service’. The story seeks in its own way to ‘carry’ the emotion transmitted by the protagonists of the story, thus proposing to literature, in a formula that I have already quoted as it seems to me to be exemplary, the
Emmanuel Carrère, D’autres vies que la mienne (Paris: POL, ), p. . Carrère, pp. –. Carrère, p. .
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role of ‘binding up what can be bound up’. Carrère will become in some way a public writer, reducing the literary project of the work to that of a commission: ‘Someone said to me then: you are a writer, why don’t you write our history? It was a commission, I accepted it.’ He takes as a model this judge who ‘in front of the sufferings of others, . . . instinctively finds the posture that allowed him to bear his own when he was suffering from cancer’ and deduces from it an ethic of literary speech: ‘Do not try to find what to say intelligently, let the words that come out of his mouth come: they are not necessarily the right ones, but it is only like that that the good ones have a chance to come out.’ It is a question of putting oneself at the service of others through literary words: it is a question of passing on an emotion that does not belong to the author, who is only a temporary medium: ‘I was excited by the idea of a brief narrative, something that would be read in two hours, the time we had spent at Etienne’s, and that would share the emotion I had felt while listening to him’, Carrère explains. Together with the idea that the device of the narrative is capable of freeing itself from the barriers of identity, time, and place in order to marry and retranslate, this instrumental and rhetorical conception of literature complements the concrete devices of attention that care proposes. It places, then our relationship to others at its heart, renouncing the privilege of fictional irresponsibility and the joys of linguistic insularity that can characterize avant-garde literature. In D’autres vies que la mienne, this a minima conception of literature seems to exclude all the symbolic benefits of the writer’s situation: on the final page of the book, there is a dedication to three little girls, ‘Diane and her sisters’, who are orphaned when Juliette, whose final days Carrère describes, passes away. We find in Carrère’s story principles of narrative medicine (‘To understand the difficult situation of others by participating in their story thanks to complex capacities of imagination, interpretation and knowledge . . . to know oneself as the result of another’s vision, and . . . to give oneself as an instrument of another’s learning’). Then on an ethical level, we can also see the plural forms that care can take on according to Joan Tronto: ‘caring out’: this is the requirement of literary speech, which must turn towards the world; ‘taking care of ’: this is the need to take charge of the stammering speech of others by keeping a trace of it; ‘care giving’: this is the ethics of the narrative that strives to bear witness for the witness with all the necessary delicacy, by first obtaining their consent); care receiving
Carrère, p. . Carrère, p. .
Back cover, Carrère, p. . Carrère, p. . Charon.
Carrère, p. .
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(‘receiving care’: this is the way in which the author accepts that his own anxieties can be calmed and his own love relationships healed by the example that the beings whose path he has crossed have given him). There are many other examples of this testimonial literature and of the implementation of care linked to the encountering of disease and suffering (for example the beautiful account of Marie Depussé, Dieu gît dans les details (God’s in the Details), evoking one of the residents of the psychiatric hospital of La Borde with this formula: ‘I will try to speak about Loyse. This, at least, I owe to her. I cannot describe her face. Perhaps she was beautiful. We were all victims of the ugliness she imposed on us.’) It is easy to see the gap between this writing which is not only transitive but also provided with an addressee, written to someone, one might argue, even openly utilitarian, and the closed paradigm of the autotelic project that Barthes summarizes in one of his most ascetic propositions: ‘To know that one does not write for the other, to know that these things I am going to write will never make me loved by the one I love (the other), to know that writing compensates for nothing, sublimates nothing, that it is precisely, where you are not – that is the beginning of writing.’ On the contrary, someone like Emmanuel Carrère writes for an addressee, seeks to be loved by them, seeks to compensate for a disappearance, to sublimate suffering – and basically prefers accuracy (in the sense of descriptive precision as well as ethical delicacy) to aesthetic value. These literary representations of otherness, of its suffering or marginality, of territories and communities, in the third person, are ways in which literature undertakes corrective action. Conceived as pity and rehumanization, emotional understanding and empathy, literature is the closest to a real clinical action where the narrative I occupies the place of a doctor of souls: ‘To take care of men, is also to take care of their history’, Patrick Autréaux says as he has to tell the story of the life of an old poet he met on a trip. This idea emerges again in the form of a comparison between ‘medical semiology’ and reading in Camille Laurens (‘Medicine, like writing, is, first of all, the Science of the Other: one must learn to read and love his Face’). The writings of suffering often affirm to go beyond the centripetal self-analysis by a renewed attention to others: ‘I prefer what brings me closer to other men/people? To what distinguishes me from
Marie Depussé, Dieu gît dans les détails: La Borde, un asile (Paris: POL, ), p. . Roland Barthes, Fragments d’un discours amoureux [][A Lover’s Discourse: Fragments], in Œuvres complètes, new revised edition by Éric Marty, Vol. V (–) (Paris: Seuil, ), p. . Autréaux, p. . Camille Laurens, Philippe (Paris: Stock, ), p. .
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them. This too is new’, says Emmanuel Carrère to take stock of what the experience of pain has changed for him. Relying on care theorists as well as on a rereading of Emerson, Sandra Laugier has suggested that it is possible to remove the apparent contradiction between paying attention to oneself and attention to the other, by opposing abstract individualism to expressive individualism, which leads to a real and concrete attention to what is appropriate for the other, because it disperses the illusion of autonomy. It is from such a dialectic that contemporary literary texts proceed: there is no solution of continuity between the care of oneself and the empathy for others, affirm many thaumaturgical accounts: the individual suffering and its cure have for correlate an increased attention to others. This is the promise of autotherapeutic speeches, such as when Hervé Guibert affirms that ‘it was necessary to find beauty in the sick, the dying’ or when Pierre Guyotat in Coma, a long and poignant account of hospitalization, describes a ‘crisis which had brought me to the edge of death’. As part of this crisis, the narrator manages to ‘advance in the formation of my language and in the knowledge of the world – and in my stripping before the richness of the others’ by allowing for the convergence between the discovery of its weakness and the enrichment of the perceptive vocabulary directed towards others. This ethic of care and its unerring faith in empathy is prone to receive scepticism: we remember that La Rochefoucauld characterized pity in his Maxims as ‘a feeling of our own ills in the ills of others’ whose value would be purely to be a preventive insurance against our own sufferings and has been the object of theoretical denunciations from all sides. It remains nevertheless a determining feature of contemporary literature in French language and answers to an immense societal demand for attention, relation, and repair.
Carrère, p. . See Sandra Laugier, ‘Ne pas laisser l’individualisme à la droite’, La Revue socialiste, (October– November ), – [accessed February]. Hervé Guibert, Le Protocole compassionnel [Compassion Protocol] (Paris: Gallimard, ), p. . Pierre Guyotat, Coma (Paris: Mercure de France, ), p. . Pascal de Duve, Cargo Vie: récit (Paris: JC Lattès, ), p. . François de La Rochefoucauld, maxime . See Suzanne Keen, Empathy and the Novel (Oxford: Oxford University Press, ), p. .
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Literature in Collaboration The Work of Literature in the Critical Medical Humanities Angela Woods and James Rákóczi
Over the last ten years, the UK has seen a sharp increase in the number of intellectually ambitious, humanities-led research investigations of health and human experience. Literature and medicine have become newly entangled in the space and service of large-scale, interdisciplinary research projects. With major investments from the Wellcome Trust, as well as funding from the Leverhulme Trust and Arts and Humanities Research Council (AHRC), these multi-year research programmes in the UK have brought literary studies scholars together with experts by experience, health professionals, artists, engineers, designers, and academics from a wide range of disciplines to investigate topics extending from breath and voice-hearing to the operation of shame in medicine and the imagined futures of assistive technologies. We conducted in-depth interviews with literary studies academics who have worked in these contexts in order to gain an insider understanding of interdisciplinary collaboration. Our aim was to explore how ‘the literary’ (as discipline, approach, and praxis) features within project design and delivery, the roles taken up by the literary studies scholar, and the consequent effects on shared understandings about the functions of the literary text. A hefty amount of scholarship addresses the mobilization of ‘the literary’ in medical education and clinical practice yet little if any sustained attention has been paid to its role within health research. This chapter contributes both to the study of ‘interdisciplinarity in action’ and to wider debates about the usefulness of This research was funded by the Wellcome Trust [Grant number /Z//Z]. Alan Bleakley, Medical Humanities and Medical Education: How the Medical Humanities Can Shape Better Doctors (London: Routledge, ); Merve Emre, Post-Discipline: Literature, Professionalism, and the Crisis of the Humanities (Chicago: University of Chicago Press, forthcoming). Rita Charon, Narrative Medicine: Honoring the Stories of Illness (Oxford: Oxford University Press, ). Felicity Callard and Des Fitzgerald, Rethinking Interdisciplinarity across the Social Sciences and Neurosciences (London: Palgrave Macmillan, ), p. ; Felicity Callard, Des Fitzgerald, and
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literary study, by being the first to analyse the role of literature within projects which exemplify the critical medical humanities. Tensions have for a long time been acknowledged around the work of literature’s ‘instrumental role in medical education’ versus its ‘non-instrumental value’ as a ‘“counterculture” to medicine’. Josie Billington notes how many literary scholars are concerned about ‘literature’s being made merely instrumental, a prop to a health agenda of targets and outcomes’, and counters that ‘the truest usefulness’ which medical humanities must make the case for ‘depends upon deep reading, not just surface relevance, both to fulfil literature’s wide human utility and to avoid its parasitic appropriation’. Rita Felski makes a similar counterstrategy, calling for an ‘expanded understanding’ of use in literary studies, one which is ‘not always strategic or purposeful, manipulative or grasping’. These interventions indicate broader trends about the conceptual reach of use (and uselessness) within academic, research, and funding metrics. For medical humanities researchers, these debates have crystallised around a ‘critical’ turn in the mid-s. Motivated by a concern that prior models of the medical humanities acted only as a ‘helpmeet’ to the biomedical industry, this turn seeks both a ‘closer engagement with critical theory, queer and disability studies, activist politics and other allied fields’ as well as a more productive entanglement with ‘biomedical cultures’ in order to expand the possibility of what interventions the medical humanities ‘can’ achieve. The aim of this chapter, therefore, is to offer a substantial documentation of literature’s work and workings in the critical medical humanities, without casting aside the binds which instrumentality and non-instrumentality debates carry us towards. What is happening to literature, literariness, the literary text, and the literary scholar as they get caught up in collaborative, interdisciplinary, critical, and health-related projects? What are the theories of literature that emerge – not in abstraction, contemplation, or op-ed rhetoric but on the ground: in negotiation with funders, colleagues, managers, administrators, and within sector-wide conditions of precarity, overwork, and (occasional)
Angela Woods, ‘Interdisciplinary Collaboration in Action: Tracking the Signal, Tracing the Noise’, Palgrave Communications, , (), – . Rita Felski, Uses of Literature (New York: John Wiley & Sons, ); Nathan Snaza, Animate Literacies: Literature, Affect, and the Politics of Humanism (Durham: Duke University Press, ). William Viney, Felicity Callard, and Angela Woods, ‘Critical Medical Humanities: Embracing Entanglement, Taking Risks’, Medical Humanities, , (), –; The Edinburgh Companion to the Critical Medical Humanities, ed. by Anne Whitehead and Angela Woods (Edinburgh: Edinburgh University Press, ). Jane Macnaughton, ‘Why Medical Humanities Now?’, in Medical Humanities, ed. by Martyn Evans and Ilora G. Finlay (London: BMJ Books, ), pp. –. Josie Billington, Is Literature Healthy? (Oxford: Oxford University Press, ), p. . Felski, pp. –. Viney, Callard, and Woods, p. .
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Literature in the Critical Medical Humanities
intellectual joy? There are three strands of literary scholarship that this chapter will address: the use of literature as a discipline, the practice of (literary) criticism and the epistemology of the text, and the risks and challenges faced within literary medical humanities projects. Behind these three strands stands the literary scholars themselves, who must negotiate with, inform, and gather expertise over these shifts in literature’s use. It was to them that we turned.
Literary Labours: Empirical Investigation Departments of English have played a prominent role in the development of the medical humanities in the UK at a time of great transition in the wider research environment. Increasingly there is pressure on humanities academics to apply for competitive research funding, to show how their research ‘impacts’ wider society, and to work more collaboratively, especially with colleagues in STEM subjects. The critical medical humanities projects which are our focus here can be seen both as structurally enabled by these shifts and highly valued because of them. Our first step in designing this exploratory study was to identify interdisciplinary medical and health humanities research projects in which literary studies had a structural role, either through the focus of inquiry or the academic affiliation of principal and co-investigators. We did this initially through our own networks, cross-referenced with projects listed on the Wellcome, Leverhulme, and AHRC websites. The projects identified ran for between twelve months and ten years, with funding of between £, and £,,. As no empirical research has previously been undertaken on this topic, we wanted as a first step to understand some of
Notably the Centre for Humanities and Health at King’s College London, the Centre then Institute for Medical Humanities at Durham University, the Centre for Medical Humanities at the University of Leeds, the Birkbeck Centre for Medical Humanities, and the Wellcome Centre for Cultures and Environments of Health, University of Exeter. Nigel Wood, ‘The Public Sphere and Worldliness: The Present Dialogue with English Studies’, in English Studies: The State of the Discipline, Past, Present, and Future, ed. by Niall Gildea and others (London: Palgrave Macmillan, ), pp. –. They included: Beckett and Brain Science (University of Warwick, Birkbeck University of London and Reading University, Arts and Humanities Research Council, ), Hearing the Voice (Durham University, Wellcome Trust –), Tipping Points (Durham University, Leverhulme Trust –), The Life of Breath (Durham University and University of Bristol, Wellcome Trust, –), Waiting Times (University of Exeter and Birkbeck University of London, Wellcome Trust, –), Threshold Worlds (Durham University, Institute of Advanced Study and Wellcome Trust via a Development Award to the Institute for Medical Humanities, –ongoing), Shame and Medicine (University of Exeter, Wellcome Trust, –ongoing), Scenes of Shame and Stigma in COVID- (University of Exeter, UKRIAHRC, –), Imagining Technologies for Disability Futures (University of Leeds, – ongoing); Living Bodies Objects: Technology and the Spaces of Health (University of Leeds, – ongoing).
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the commonalities and discontinuities across these academic spaces as experienced and perceived by literary studies academics. We therefore decided to focus initially on those who were involved in two or more such projects and could bring a comparative perspective. After obtaining approval from the Durham University Ethics committee, we invited the eight individuals who fulfilled these criteria to participate in an in-depth interview via Zoom. Everyone responded with enthusiasm to our invitation, but one colleague could not participate for reasons of time and workload. The seven semi-structured interviews we conducted together ranged from to minutes in length and were professionally transcribed. Our interviewees – three men and four women – were, with the exception of one medievalist, scholars of modern and contemporary anglophone literature and culture. They had varied roles and responsibilities within each project. Six had been principal investigators (PIs). Two had been employed as fixed-term postdoctoral research fellows prior to becoming PIs on subsequent projects. All now have, or have recently retired from, permanent (tenured) academic positions. Although we recognize that full anonymity is not a practical possibility with such a small and specialized sample, we have nevertheless endeavoured to limit identifying information in presenting our analysis of key themes raised across the interviews. Notwithstanding the exploratory and small-scale nature of this study, a significant limitation is its bias towards those individuals for whom critical medical humanities projects have been career-enhancing and in other ways worthy of repeated investment. As well as producing more detailed projectby-project case studies which capture the views of a larger group of investigators, collaborators, and other stakeholders, and of course extending the focus beyond the UK and especially to multilingual and non-anglophone contexts, future research should also investigate the perspectives of those with more limited participation in critical medical humanities projects, including those whose plans and ambitions were not able to be realized.
Figuring Out ‘the Literary’ Doing English in educational settings ‘involves reading works of literature, learning to interpret them in different ways and understanding how these different approaches work’. Doing English within an interdisciplinary
Robert Eaglestone, Doing English: A Guide for Literature Students, th edn (London: Routledge, ), p. .
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Literature in the Critical Medical Humanities
medical humanities project is, according to our interviewees, a very different kind of endeavour which somewhat counter-intuitively decentres both the literary text and forms of distinctly literary criticism. Before it signals privileged access to a set of primary sources, or expertise in a specific set of research methodologies, ‘the literary’ was most often invoked by our interviewees as something more expansive – an orientation, approach, or sensibility. Training in literary studies had given one interviewee ‘a really fine ear for messiness and contradictions and narratives that don’t make sense’, a sentiment echoed by another interviewee for whom the value of literature lies in its capacity to ‘contain and hold mess without resolution . . . holding onto inconsistencies and contradiction’. Contradictions could extend to counterfactuals: as a third interviewee put it, ‘the literary may be a way of articulating both the world as it is’ and ‘a space for thinking about the world as it might be different’. Being a literary studies scholar meant being alive to and comfortable with ambiguity and with imagining otherwise, qualities the interviewees recognized as particularly valuable in contexts where the complexities of illness experience and the ‘terminological negotiations’ of interdisciplinary collaboration were in play. This celebration of tolerating uncertainty resonates across formulations of what medical humanities can offer healthcare and medical education, as well as with Ben Knight’s description of literary studies as a ‘boundary practice’. Across the projects we looked at, ‘the literary’ functioned in excess of itself, as co-extensive with or as a vector for critical theory, the history of ideas, philosophy, critical phenomenology, complex systems thinking, linguistics, narratology, pedagogy, postcolonial studies, political economy, psychoanalysis, temporal studies, care studies, and broader notions of ‘historical context’. In some contexts, ‘the literary’ existed in continuity with other disciplines, as when the lives of English mystics, for example, were the subject of collaborative investigation by historians, theologians, and scholars of medieval literature. In other contexts, schisms in the way literary studies scholars perceived the nature, purpose, and value of their endeavour and its contribution to interdisciplinary working were pronounced. One interviewee described how broader political events
Marco Bernini and Angela Woods, ‘Interdisciplinarity as Cognitive Integration: Auditory Verbal Hallucinations as a Case Study’, WIREs Cognitive Science, , (), – . Neepa Thacker, Jennifer Wallis, and Jo Winning, ‘“Capable of Being in Uncertainties”: Applied Medical Humanities in Undergraduate Medical Education’, Medical Humanities, , (), – . Ben Knights, ‘English on Its Borders’, in English Studies, ed. by Gildea and others, pp. –.
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motivated a reorientation of their work: ‘[M]y role shifted away from thinking about what it is that literature could give to the project, so much as how the political dimensions of having some training in post-colonial literature could at least get people talking about or thinking about the political dimensions of the project.’ However, in its theoretical orientation, this ‘more expansive notion of the tradition of literary criticism and literary studies’ was met with resistance by the project’s ‘traditional literary scholars’ whose approach to ‘literature as culture’ the interviewee viewed as more ‘historical and historicist’. If the varied foci and theoretical orientations within literary studies stretched the boundaries of the discipline – by emphasizing either similarities with other humanities scholars or the incommensurability of approaches ‘within’ literary studies – our interviewees also spoke positively about occasions where they felt released from the constraints of disciplinarity: [The PI] liked to talk up my importance as a disciplinarian because I brought something in terms of that, but what was more effective when I think about it was her willingness to say, well we’re going to just be people in a room hashing out ideas. . . . [When we] were much more interested in unpicking the theoretical bounds of an idea and much less interested in guarding our disciplinary turfs, we were much more able to bring skills to bear or knowledges that were . . . only incidentally related to our disciplines . . . With literary studies there’s a preoccupation with language, with how language works, with how language fits in to a broader context and why it has particular implications. On the basis of that, we were able to then say, well what are the different things that people would think about when they think about [a specific health condition]?
This release from the pressure to ‘perform what it is that a literary scholar is or does’ was framed by interviewees as a paradoxical return to some of the discipline’s most essential modalities. Literary studies was, to varying degrees, a structural feature of these critical medical humanities projects, but although it was ‘written in’ to the identification of research questions, description of work packages, and rationale for specific posts, the function or purpose of ‘the literary’ was seldom if ever explicitly articulated in applications for funding. Our interviewees regarded this as a positive development, a liberation from the need felt by many to justify or defend the value of humanities perspectives to interdisciplinary inquiry (enabled especially when principal and co-investigators themselves came from literary studies backgrounds). Nearly all the projects discussed by our interviewees were designed to
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address questions and problems of health and experience, in which context again the broader orientations of a discipline were just as salient as the specificities of subject or methodology: at heart both projects were initially idea driven, and the ideas were the complexities, and it was my approach to those complexities that necessarily came through the lenses of the subject areas in which I worked. . . . So in order to think through the kind of complex intersections and interweavings [of the topic . . .] the place of literary studies was both my natural way into the project and also something that I immediately understood had to be expanded. Because were it limited to that approach, it would not be the kind of project, one, that would do much good in terms of thinking about the issue in the round, and two, that would get funded.
These were not, in other words, literary studies projects adapted to serve critical medical humanities agendas, but projects in which literary studies was from the outset understood to play a role within the wider ecology of expertise deemed necessary to tackle the topic at hand.
Epistemologies of the Text One of the most notable consequences of this disposition is how it has informed a set of fresh working definitions of the literary text itself. Interviewees clearly treated literary texts as an abundant and multivalently functional resource. We were struck by these playful operationalizations, in which the text came to signify multiple and intersecting possibilities within critical medical humanities projects. Texts, we were told, were and were not like data drawn from interviews or testimony from lived experience; they acted similarly to historical archives and case studies from the past, but not in straightforward ways. They could function as empirical data akin to those derived from the psychological study or medical case history, but also act as sites of speculative intuition like that of the philosophical thought experiment. Throughout the eleven or so hours of our conversations, it seemed imperative for the literary text to be in dialogue with other forms of record (historical, experiential, scientific), and for their differentiation to be recognized and reckoned with. Every one of our interviewees outlined how this ‘and/or’ quality took hold through their determination for the text to be considered in nonrepresentational terms. This is not to suggest that representational understandings of literature were always considered without value, but this value was often framed as a strategic starting point – either for funding
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applications, discussions with project partners, or as a necessary first step in interdisciplinary co-design. One interviewee described, for example, how the literary text was initially ‘perceived as a source for representation’, but then noted how project collaborators ‘started to talk about what that representation involved and about the more formal aspects of literature . . . [including] the relationship between narrative and complexity’. This particular project’s funding bid had assigned literary scholars initially to the task of surveying texts with representations of climate change. Yet, in practice, they had examined through literature the more complex question of ‘how change occurs’. Another interviewee noted that literary texts are often used by scientists and philosophers as ‘cosmetic’ representations. They reflected how their project began ‘from there’ but went much further as many conversations about the ‘epistemological status of literature’ unfolded, such that by the project’s end, an ‘exemplificatory or illustrative function of literature was not in the design’ at all. Other interviewees, however, portrayed this process as more fraught, the challenge of convincing collaborators ‘out of the mindset’ of representationally reading a literary text as a ‘consumable, cultural object’ having not been surmounted. These shared refusals to restrict the text solely to a representational function suggests how the literary text is accruing new values to demarcate further possibilities in health-related research. One interviewee, for example, described the difficulty of being positioned between literary studies and care studies, where researchers of the latter sometimes figure the literary text as an exemplary ‘tool’ to teach good (or bad) care practices. To move beyond this, our interviewee described creating spaces in critical medical humanities projects to consider the ‘techniques involved in reading’ in ways which highlighted how literary attentiveness to specificity and detail mirrored aspects of care practices themselves. Several interviewees repeated similar sentiments when discussing how literary texts can act as windows on the workings of mind, perception, and cognition. One interviewee recalled a psychologist colleague’s view that ‘what literature does’ is allow ‘insight into degrees of interiority that are just impossible through conventional experimental, psychological, or ethnographic data’ collection. At the same time, these affirmations for how literature draws out aspects of interiority for psychological analysis were also quickly complicated. Interviewees insisted that if literary texts are to be understood as able to extract data about interiority, then they cannot be understood as that data but as a method, and a method requiring further methodologies. Such inflections have produced new concepts of
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the literary novel as modelling cognitive processing or complex systems. One interviewee, for instance, spoke about how they have come to see literary texts as a ‘form of investigation’ that ‘should be parallel and compared and exchanged with the scientific ones’. Another, drawing on a claim made by Ju¨rgen Habermas in Philosophical Foundations of Modernity, drew an explicit analogy between text and disciplinary method: There are disciplines that are world-building and disciplines that are worldcritiquing. And I thought, well, actually my discipline does both, and I think a novel does both. I think it builds a world but it’s also offering a critique. It’s at an oblique angle to the world you’re in, and it’s connected to it in a number of ways but it’s also not connected to it. So it allows you to reflect on your own world and the experiences in your own world, because of that oblique angle – perspective – on everything.
The relationship between the literary text and other forms of historical data was another key theme across our interviews. Challenging the ‘simplistic’ view that ‘literary texts could just offer case studies of the past’, one interviewee advanced the view that fiction is better thought of as ‘opening a window onto understanding . . . the kind of beliefs, assumptions, attitudes at work in the world’. Insights into ‘imaginative creation and the ways ideas work’ that ‘you can’t get . . . from [other] historical records’ demand specialized tools and techniques, for example in the analysis of genre. Fredric Jameson’s famous injunction to literary critics to ‘always historicize’, then, is complicated by how critical medical humanities researchers are drawn to outline and explore an additional ‘artefactual quality’ of the literary text. Attending to its distinctiveness, if not strangeness, another interviewee affirmed the value of the literary text not just in ‘thickening out historical context’ but in taking the reader ‘into other realms that are less easily . . . perhaps sometimes less easily excavated’. These critical medical humanities projects are not only producing new epistemologies of the literary text but competing ones as well – nascent formations of what will perhaps become major debates in future literary
Marco Bernini, Beckett and the Cognitive Method: Mind, Models, and Exploratory Narratives (New York: Oxford University Press, ). Patricia Waugh, ‘The Novel as Therapy: Ministrations of Voice in an Age of Risk’, Journal of the British Academy, (), –. Ju¨rgen Habermas, The Philosophical Discourse of Modernity: Twelve Lectures, st edn (Cambridge: Polity, ). Fredric Jameson, The Political Unconscious: Narrative as a Socially Symbolic Act (Oxon: Routledge, ), p. ix.
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scholarship. This came to light in how different interviewees described the relationship between historical and experiential time. One interviewee saw the emergent epistemology of the text as dependent on its formal capacity to both take ‘time in a particular way, but also . . . form time’. The text here acts as binding agent: it gives, lends, and constructs form ‘to make a set of experiences manageable’ and in doing so holds ‘what Wilfred Bion would call nameless dread’. Engaged research associated with this interviewee’s project took place where literature was itself emergent as a ‘basic literary impulse’: to ‘take experience and to form it and bind it’ meaningfully. A deferring account of the literary text’s qualities was offered by another interviewee. They described how early texts of narrative theory, such as Kermode’s Sense of an Ending, offer an account of story as conferring ‘retrospective significance’ through the construction of beginnings, middles, and endings in ways that life does not. Kermode’s argument could be read, then, as rendering such a ‘basic literary impulse’ as primarily ‘consolatory’, when we must account for how people are ‘disturbed’ by literary texts too. It is to be expected that different definitions of literary texts would emerge across projects with divergent matters, time periods, scales, and objects of research. We highlight this in order to consider how critical medical humanities research projects are producing multiple articulations of the literary text in relationship to their instrumental – or even therapeutic – promise in ways that are constituting important, original theories of textual objects. We found that researchers, through their justifications of literature’s inclusion and maintenance in project design, practise a kind of renewed faith in the literary text. This faith stands in relation to, but moves significantly beyond, the instrumentalization of literary texts that characterize first-wave medical humanities projects (such as training in empathy, reading for healing, or other ‘humanizing’ skills). As one interviewee put it, their time on critical medical humanities projects ‘solidified my sense that there’s something complicated happening when you put words together in particular sequences on a page’. This complicatedness, frequently evoked, echoed Ato Quayson’s definition of the literary text as ‘a variegated series of thresholds and levels, all of which determine the production of the social as a dimension within the interaction of the constitutive thresholds of literary structure’. Critical medical humanities projects witness how the literary text becomes constituted as a form both of ‘aesthetic particularity’ but also
Ato Quayson, Calibrations, NED-New edition (Minneapolis: University of Minnesota Press, ), p. xvi (italics in the original).
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‘a threshold, opening out onto other levels of cultural and sociopolitical life’, a means of producing what Patricia Waugh describes as emergent ‘styles of thinking’. This brings us to the final feature of the literary text we wish to draw attention to here: how these theories of the text emerge and circulate through the collaborative architecture of medical humanities projects. We were interested in how specific literary texts come to function as commons, as sites of gathering for the multiply deferring disciplines of interdisciplinarity. Notably, many interviewees did not identify literary texts in this regard, or noted that it often was not literary texts that provided moments of gathering, but a literary sensibility which was applied to non-literary texts – such as works of phenomenology (Merleau-Ponty) or design (Dunne and Raby). One interviewee observed that events such as reading groups, seminars, and conference panels where multidisciplinary partners would gather round a sole literary text were occasions where friction, rudeness, and micro-aggression could surface. By contrast, others affirmed the ability of literary texts to produce collegiality and shared understanding for a whole team. Buchi Emecheta’s semi-autobiographical novel Second-Class Citizen was highlighted as an exceptional case in point. In offering a first-hand account of a Nigerian woman’s encounter with British healthcare in the s and s, the novel brought to the surface experiences which were ‘harder to excavate from other kinds of documents’ thus ‘fleshing out the history of the NHS’ in that period. Literary texts are often the available objects of medical humanities projects – straightforwardly publishable, printable, sharable, and even popular in ways that archival objects and sensitive data from interviews are not. Through this reproducibility, we found that the text additionally comes to function as a site to hold diverse interpretive impulses, to reflect (in ways that other forms of data or argumentation may not) the sometimes confusing abundance and thickness of a project’s themes. As one interviewee put it, texts are ‘so contradictory and that’s the joy of them, I don’t want to solve these, I just want to talk about things in their messiness and
Felski, p. . Patricia Waugh, ‘Discipline or Perish: English at the Tipping Point and Styles of Thinking in the Twenty-First Century’, in Futures for English Studies: Teaching Language, Literature and Creative Writing in Higher Education, ed. by Ann Hewings, Lynda Prescott, and Philip Seargeant (London: Palgrave Macmillan, ), pp. –. Maurice Merleau-Ponty, Phenomenology of Perception (New York: Routledge, ). Anthony Dunne and Fiona Raby, Speculative Everything: Design, Fiction, and Social Dreaming (Cambridge, MA: MIT Press, ). Buchi Emecheta, Second-Class Citizen (London: Heinemann, ).
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their contradictory nature’. What literary studies gives, and what the text as celebratory or vexed gathering provides, is this ‘ability to discuss contradictions and messiness’.
Labours of and on Collaborative Projects Because the work of literature in critical medical humanities reaches across, and resists, the range of uses assigned to literature by non-literary PIs and collaborators, we were interested in learning how this manifested in the experiences of literature researchers themselves. What kinds of labour were they called upon to do as these projects developed, and was any of this labour unexpected – or unwanted? Further, in what ways did the material circumstances of the project enable and/or disable these labours? There has been a body of recent scholarship on how the objectives and delimitations placed upon health-related research projects by funders and universities may mismatch in ways which make research aims constitutively impossible, for example with respect to patient involvement, public engagement, and collaboration with clinical/healthcare partners. Here, we offer literature as a further site where frictional demands are placed upon healthrelated researchers and their aims. A glance at any list of outputs of critical medical humanities projects will quickly reveal how researchers are mobilized to perform a wide array of tasks, some well outside of their usual expertise. These range from appearing in public events and festivals, curating exhibitions, and producing and directing plays, to personally engaging with those with lived experience of illness in therapeutic and activist contexts. There is often a division of labour in how these tasks are coordinated. Some encountered the expectation that humanities researchers were better equipped for these endeavours or in some sense more predisposed to them. We were interested in understanding more about which tasks people felt called upon or
The foregoing discussion reflects our interviewees’ experience, as literary studies scholars, of being recognized by their project collaborators as having privileged if not authoritative access to the literary text. It would be fascinating to study further how this relates to and might be complemented or challenged by the writers working in these collaborations, often with the brief of producing new work. Eivind Engebretsen, Gina Fraas Henrichsen, and John Ødemark, ‘Towards a Translational Medical Humanities: Introducing the Cultural Crossings of Care’, Medical Humanities, , (), e–e; Stan (Constantina) Papoulias and Felicity Callard, ‘“A Limpet on a Ship”: Spatio-Temporal Dynamics of Patient and Public Involvement in Research’, Health Expectations, , (), –; Veronica Heney and Branwyn Poleykett, ‘The Impossibility of Engaged Research: Complicity and Accountability between Researchers, “Publics” and Institutions’, Sociology of Health & Illness, , S (), –.
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pressured to do, and which of them contributed to their own understanding of literature. One interviewee described two occasions where they felt a renewed pressure on their work. The first was an engagement event held in the spirit of a science fair, where researchers set up various stalls in order to facilitate informal discussion with people with lived experience. Our interviewee found this distinctly ‘uncomfortable’ because ‘we were engaging with people . . . for whom [these texts’ subject matter] wasn’t a creative liberation but was being experienced as an extreme form of pain or suffering’. This discomfort, however, was recognized as deepening the researcher’s own understanding. A second encounter, this time with the transcriptions of interviews with people with lived experience, had similarly powerful effects: ‘I read them all, I read them twice’ and realized again how this project was ‘a terribly responsible thing to be doing, and that you wanted to do justice, not just appropriate people’s experiences’. Many of the interviewees expressed a sense of good fortune at having become involved in critical medical humanities projects, being exposed to new disciplines, methods, and bodies of knowledge, as well as new experiences and voices. One interviewee suggested that their ‘artificially positive’ experience may not provide an accurate picture of collaborative or interdisciplinary working, suggesting they were likely in a ‘bubble’ having ‘not had to justify and defend literary approaches, the way that I think many people need to’. Another interviewee said they felt ‘lucky’ because they had never ‘had to argue for the value of the literary’, while a third outlined that it was only occasionally that they had to argue ‘relatively aggressively’ for the inclusion of literature in health-related conversations elsewhere in the institution. This sense of fortuity may be driven by what one interviewee described as the centrality of ‘trust’ in successful critical medical humanities projects: ‘trust is the key for interdisciplinary work, but trust comes paired I think with seriousness, in terms [of] being taken seriously’. They distinguished trust from ‘respect’, because ‘respect’ can easily become confused in an ‘interdisciplinary environment with condescension’. When reflecting on the exact labour involved with maintaining positive environments for literary scholars, then, many interviewees described difficult (but successful) emotional balancing acts. And as one interviewee reflected, being the literary scholar committed to working with other people produced the ‘need to perform a kind of role, a kind of Goffmanian sense of being presented as the literary scholar in the room’. This evocation of Goffman brings us helpfully to the notoriously capacious concept of emotional labour, coined by Arlie Hochschild in to define ‘management of feeling to create a publicly observable facial
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and bodily display’. Hochschild acknowledged her indebtedness to Goffman in a edition of her classic text, ‘for his keen sense of how we try to control our appearance even as we unconsciously observe rules about how we ought to appear to others’. There was a repeated sense from interviewees of a balancing act which operated along these lines. The specific challenges and feelings faced by early career researchers in interdisciplinary contexts were captured by one interviewee in their discussion of the challenges around publishing and interdisciplinary authorship: When you feel like, oh I spend so many energies there, and my name is one of twelve [named authors on a scientific paper] and we need to go for nine more articles of this kind, and I’m struggling to publish my own individual thing this year . . . it can be . . . it’s not a frustration but . . . you’re also becoming like a bit estranged sometimes from your own department and people having to get jobs . . . clearly there are a lot of emotions going on, which I think if they are poorly managed, I think it can be . . . it’s a risky business . . . [Interdisciplinary work] can really make someone feel worse than he or she would have felt outside of it.
In the UK, employees of the university sector have faced deteriorations in working conditions, actual and threatened job losses, as well as counterwaves of industrial action coordinated by the Universities and Colleges Union from . As Amia Srinivasan states, the ‘spirit of vocation and reciprocity’ is one reason why people aspire to academic labour, but when ‘people insist that the university is simply a place of love, and not also a place of work, they offer cover to exploitation – of staff, of students, and of the ideals of the university itself’. Precarious or unstable circumstances affected all interview subjects (correlating in intensity with job security or career stage), revealing the material concerns which underpin the construction and formation of
Arlie Russell Hochschild, The Managed Heart: Commercialization of Human Feeling (Berkeley: University of California Press, ), p. . Hochschild, p. xviii. Sophie Jones and Catherine Oakley, ‘The Precarious Postdoc: Interdisciplinary Research and Casualised Labour in the Humanities and Social Sciences’, in Working Knowledge: Transferable Methodology for Interdisciplinary Research, ed. by Charles Fernyhough, Angela Woods, and Victoria Patton (Hearing the Voice; Durham University, UK, ) [accessed September ]. Angela Woods, ‘Interdisciplinary Authorship’, in Working Knowledge: Transferable Methodology for Interdisciplinary Research, ed. by Charles Fernyhough, Angela Woods, and Victoria Patton (Hearing the Voice; Durham University, UK, ) [accessed September ]. Amia Srinivasan, ‘Back on Strike’, LRB Blog, December [accessed May ].
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collaboratively engaged literary scholar identity. ‘Clearly you need to feel like you are not just contributing collectively, but also that you are building, crafting’ with your own literary expertise. We found the metaphors offered of labour and professional development particularly instructive. One interviewee described being involved in collaborative projects as ‘the two stages in learning a new language: you feel like you’re passing reception . . . and then there is a production moment. In between, if things go wrong, there can be mutism.’ This same interviewee added that at some point the excitement of this process ‘naturally declines because you . . . realise “I’m not here to become a scientist”’ but instead remain a literary scholar. Many of our interviewees noted the elasticity required by critical medical humanities projects and reflected upon how to place personal and professional limits on that stretching in order to maintain a coherent sense of literary scholarly identity. As another interviewee put it: this is ‘insecure’ work, ‘the ground shifts beneath your feet’, and they added that this insecurity regularly extended into the difficult subject matters they brought to students in seminar spaces. Others reflected on the challenge and excitement of working on pathways that have not yet been ‘paved’, and how such ‘emergent sets of practices’ rely on groupwork, a group ‘committed to reading and writing and thinking together’. Finally, a number of interviewees expressed the need for an article not unlike this book chapter that laid out ‘strategies that have or have not worked for others’.
Risks and Challenges One interviewee described a major exhibition which came about towards the end of their project as ‘a coalition of events’ which ‘clearly wouldn’t have been possible’ on day one. The events ‘spoke to each other in a way that was holistic’ and ‘dynamic’, and also spoke to how the project’s literary component was leading to ‘the decompartmentalization of problems and experiences’. On this interviewee’s account, the contribution of the ‘literary domain’ developed over two movements. First, what are found ‘immediately’ in literary texts are ‘a constellation of nuances’ that, for those ‘coming from the sciences’, can feel like a ‘new interpretive toolbox’. Second, the ‘immense potential of literature’ is disclosed through how this interpretive toolbox comes to be understood as exceeding the possibilities of what can be revealed in a localized laboratory. It ‘can create strange forms of new experiences to render the complexity, richness, and global experiencing of the project’. It was in this second movement that this interviewee suggested that literary scholars found their confidence, a
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sentiment complemented by other interviewees as they described how the significance of nuance, complexity, and complication that literature offered came to be recognized as significant by their respective project partners. Staked on the promise of its complexity, however, literature’s use and justification are therefore fraught with risks and challenges. We will consider three here: durational inconsistency, misunderstanding, and the need for spaces conducive to possibility. One challenge which became apparent in the interviews was a recurrent disagreement to be negotiated over the temporal or durational demands of research – indeed, earlier we outlined how these demands impacted emotion work. As one interviewee noted, scientists have very different demands placed on them about publication compared to humanities researchers. This led to disparate rates of publishing research: with literary researchers feeling devalued and scientists feeling frustrated by the longer intervals of humanities publishing schedules. The work over many years towards the single-authored monograph that is still so highly prized in the humanities and so vital to career progression can be difficult to make space for, or make visible, within the collaborative endeavour: reading a novel or a work of theory can be slow, in an era of the academy where work must be fast. Another incongruity of duration was described between literary and clinical collaborators. One interviewee described a psychiatrist, in response to an extended discussion of creative approaches, ‘ultimately saying, well I have to give a diagnosis . . . I need to prescribe in this instance’ in order to fulfil my responsibilities as a clinician. Lisa Diedrich has described this phenomenon as a ‘compassion’ imperative of health research, a drive to act immediately in the face of therapeutic emergency which prevents ‘the possibility of enacting new theories and politics in and for medicine’. Managing differing attachments to temporality and urgency was, in some cases, foregrounded by the critical medical humanities projects themselves. Another interviewee reflected upon how clinicians, however willing to ‘get on to thinking creatively and expansively with literary ideas’, need time to be ‘given over for them to [talk through] how difficult their working lives are at the moment . . . there’s something about the really hard reality of clinical engagement’ that needed to be aired at the start of any gathering.
Lisa Diedrich, ‘Against Compassion: Attending to Histories and Methods in Medical Humanities; Or, Doing Critical Medical Studies’, in Narrative Matters in Medical Contexts across Disciplines, ed. by Franziska Gygax and Miriam A. Locher (Amsterdam and Philadelphia: John Benjamins Publishing Company, ), pp. –.
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We had hypothesized that interviewees might report difficulty in the misapprehension of literature’s role. About half of our interviewees did recall experiences of this nature, though sometimes in medical humanities work they had participated in before the critical medical humanities projects they had come to be a part of. One interviewee described their initial difficulty in getting funding for interdisciplinary work because the majority of key project partners were from similar literary backgrounds. This parallels Callard and Fitzgerald’s observation that an ideal of interdisciplinary collaboration stipulates that scholars in the humanities and social sciences should be lending support to scientists (the supportive function effectively overriding meaningful distinctions between the humanities and social sciences). Some viewed the many hats they wear as researchers as a net positive, an ‘exciting but unsettling’ way to have both: to learn literature and to learn about other disciplines, to practise group work, and write and publish individually. Another interviewee, however, described real challenges of being misunderstood within their projects, notably at a time when they were early career. This led them to feeling ‘split down the middle between the work that I do for literary studies, and the work that I do for medical humanities’. As a symptom of wider trends in the academy, such situations are particularly acute, and recognizable, for researchers who lack both the job security and social capital necessary to defend themselves in terms they desire. The need for professional and disciplinary security was described by some as mitigating the possibility of literary research: ‘in terms of getting a job, it just seemed that the wilder, woollier kind of interdisciplinarity just wasn’t possible’. The lesson they learned was to ‘get the job and then you can be fun after you’ve got the job’. Even then, as one senior scholar described, within wider University structures there is ‘always a feeling that you’re pushing against [those] that will assume that the workings and concerns of the literary are not predominant, should not be predominant in talking about health’. We speculate, then, that many of the emergent ideas of literature’s use-value in circulation are produced through these kind of intra-institutional negotiations as much as they reflect longsustained intellectual work. That said, the compromises that academics (and particularly early-career academics) make within the critical medical humanities context are no less valid, authentic, or impactful in contributing to legitimate shifts and movements of literature’s conceptualization. This disposition was
Callard and Fitzgerald.
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succinctly described by one interviewee who mentioned that they appreciated how our questions were attending to the ‘work literary studies is doing or allowed to do or imagined to do or actually ends up doing’: to not ‘gloss over all the tricky and uncomfortable and difficult bits, which people are inclined to do in other contexts’. Such tricky ‘bits’, then, are no less part of the give and take of how the literary is on the move and at play in healthrelated work. At the same time, one of the most striking features of critical medical humanities projects has been their long duration, their allowance of research processes to unfold rather than be predetermined, and the ability to let concepts be emergent rather than rapidly set. Many of our interviewees who have also acted as project leads cited their backgrounds in literature as key to their belief in actualizing these conditions of large-scale collaboration. ‘What literary studies gives’ to the critical medical humanities is a ‘fine ear for messiness and contradictions’ which signals a departure from any straightforward notions of patient stories as healing and promises to ‘attune’ to illness and life’s possibilities more thoroughly and attentively. The medical humanities offers a ‘huge opportunity to show why literary studies matter’ but literary studies ‘can only really be effectively in dialogue if it understands its own value’. Guaranteeing a role for the work of literature in the future of critical medical humanities requires strategies. One cannot, as one interviewee wryly observed, just throw ‘Ulysses in the scientists’ faces. It’s a big book!’ Insisting upon the capacity of literature to subvert, mediate, and transform the givens of health-related research has been one of the critical but perilously held achievements of these projects, alert to the generative challenge of being in collaborative workspaces and among people thrashing out ideas.
Arthur Frank, The Wounded Storyteller, nd edn (Chicago: University of Chicago Press, ).
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Afterword Literature and Medicine after COVID- Anna M. Elsner and Monika Pietrzak-Franger
Written at a time of crisis, Literature and Medicine betrays an awareness that the field is at a crossroads. It anticipates the many directions that researchers can take in the future, but it also records the anxieties involved in not knowing what lies ahead. The recent pandemic has redefined medical and literary pathways. It seems that the global experience of COVID- has also given priority to the medicine-to-literature direction thus reversing (and even subverting) the long-standing ‘literature-and-medicine’ pairing. While, for us, this reversal does not necessarily entail any permanent change to the field as such or cancel the dominant vectors that we associate with this coupling, it certainly defamiliarizes the literature–medicine relationship. Even though it is impossible for us – being as we are in the midst of these transformations – to capture the exact nature of this novel directionality, the effectuated denaturalization and distancing appear to us to carry with themselves unparalleled potential for the future. Literature and Medicine compels us to pose questions about the vectors within the connection and the power structures they imply. It prompts us to better define the literature– medicine relationship that has remained vaguely contoured and has often appeared all-encompassing. Finally, it obliges us to rethink the connection to include texts and practices that have so far found little critical interest in this context. While we acknowledge the usefulness of the medicine-and-literature direction and welcome its denaturalization effects, we are also very much aware of the fact that it is too early for us, and the other contributors, to embrace the full range of the resultant implications. We are very much hoping that this volume will offer a solid enough foundation for further considerations of this sort. This said, we would like to take three steps in this Afterword, which may pave the way for future forays into this area. First, we briefly sketch how the particular ‘medical’ event of the pandemic has transformed literature as medium,
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art form, and practice. By identifying some of the thematic and formal trends we have observed, we also indirectly reference the necessary methodological adjustments that we will have to take in order to be able to assess these critically. Second, with a view to these changes and the necessary opening up of the field of literature and medicine that the pandemic has made visible, we draw attention to the thematic and formal trends that may be helpful in this endeavour. What is more, we identify some of the possible future directions. Last but not least, under the heading ‘Literature and Medicine, Quo Vadis’, we indicate some of the ways in which, we believe, scholars across the medical and health humanities, literature and medicine, and humanities in general, might be going.
Pandemic Reading, Writing, and Performing The pandemic has transformed literature. This has happened to various degrees across all major genres: while some of these transformations have been relatively minor – thematic intensification in certain areas notwithstanding – some genres have faced substantial shifts and found themselves fighting for survival. New Yorker critic Alexandra Alter observes, ‘[m]ore than two years into a global health crisis that has reshaped society and daily life, COVID- is leaving an inexorable mark on literary fiction’. Indeed, it seems that the pandemic has generated literary practices of two broad kinds: it put a spotlight on particular works of literature that engage with plagues, pandemics, and diseases, and generated literary production of its own. National lockdowns brought about an intensification of reading as an individual and collective pastime. Unsurprisingly, reaching out for fiction that potentially provided meaningful frameworks for the understanding of the ‘new normal’ was one of the most prominent tendencies in the early months of . Albert Camus’s La Peste (), Daniel Defoe’s A Journal of the Plague Year (), and Philip Roth’s Nemesis () were hailed as the texts to read. New York magazine’s website Vulture also put José Saramago’s Blindness (), Margaret Atwood’s Oryx and Crake (), and Katherine Anne Porter’s Pale Horse, Pale Rider () on its
Alexandra Alter, ‘The Problem with the Pandemic Plot’, The New York Times, February [accessed December ]. Kshama Parikh, Priyanki Vyas, and Saurin S. Parikh, ‘A Survey on Reading Habit of Library Users during COVID- Lockdown’, Library Philosophy and Practice (), –.
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‘Pandemic: An Essential Reading List’. Apart from reading (post-) apocalyptic and dystopian fictions, and novels about the plague, rereading of classical and ‘comfort’ texts belonged to the most common practices. Publishers and the entertainment industry have capitalized on this trend by, for instance, commissioning new translations of La Peste – whose sales exponentially rose in the early days of COVID- – or by releasing television series based on such novels as Emily St. John Mandel’s Station Eleven (). Next to reading, gaming, and binge watching, audiences also participated in online theatre events. As different as these pastimes are, they have been seen in terms of their therapeutic and community-building value in times of crisis. COVID- has also triggered its own literary production of various kinds. As the proliferation of confinement diaries, quarantine journals, poems, or the weekly edition of Gallimard’s ‘Crisis Pamphlets’ makes clear, short poetic and essayistic forms became characteristic of the early stages of the pandemic. Zadie Smith’s Intimations: Six Essays () is exemplary. The collection is an attempt to articulate Smith’s struggle with the uncertainty of crisis. In this context, questions of accessibility to
Tobias Carroll, ‘Pandemics: An Essential Reading List’, Vulture, March [accessed December ]. Reading Novels during the Covid- Pandemic, ed. by Ben Davies, Christina Lupton, and Johanne Gormsen Schmidt (Oxford: Oxford University Press, ). Alison Flood, ‘Publishers Report Sales Boom in Novels about Fictional Epidemics’, The Guardian, March [accessed January ]. Malcolm Jones, ‘That Was Quick: Fiction Writers Are Already Publishing Their COVID Stories’, Daily Beast, December [accessed December ]. Lin Zhu, ‘The Psychology behind Video Games during COVID- Pandemic: A Case Study of Animal Crossing: New Horizons’, Human Behaviour & Emerging Technologies, , (), – ; Gwendelyn S. Nisbett, Stephanie Schartel Dunn, and Newly Paul, ‘The Escapism and Social Bond of Pandemic Binge Watching’, in Persevering during the Pandemic: Stories of Resilience, Creativity, and Connection, ed. by Deborah A. Macey, Michelle Napierski-Prancl, and David Staton, Lexington Studies in Communication and Storytelling (Lanham: Lexington Books, ), p. ; H. Cho and others, ‘I Don’t Want a Book That’s Going to Make Me Sad or Stressed Out, Especially in This Day and Age’: Fiction Reading (and Healing) in a Pandemic’, Proceedings of the Association for Information Science and Technology, , (), –; Christina Clark and Irene Picton, ‘“It Makes Me Feel Like I’m in a Different Place, Not Stuck Inside”: Children and Young People’s Reading in before and during the COVID- Lockdown. National Literacy Trust Research Report’, ERIC [accessed December ]. The pamphlets which were published between March and May included texts by, among others, Cynthia Fleury, Pierre Bergounioux, Edgar Morin, and Catherine Cusset and were made available free of charge via the Gallimard website [accessed January ]; they have since appeared in a collected volume Tracts de crise: Un virus et des hommes, mars– mai (Paris: Gallimard, ).
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healthcare also figure prominently when Smith wryly remarks: ‘Death comes to all but in America it has long been considered reasonable to offer the best chance of delay to the highest bidder.’ British author Michael Rosen chose the poetic form to ‘record’ his COVID- recovery journey, thus turning the most mundane, simple, uneventful activities into sites of combat and longing. But his collection does not only offer a space for the expression of his subjective experience; it also pays tribute to Rosen’s (and all) caregivers. The poem ‘These Are the Hands’, written for the sixtieth anniversary of the NHS, crowns the collection with a tribute to the ‘invisible’ yet invaluable labour of care: ‘And these are the hands / That stop the leaks / Empty the pan / Wipe the pipes / Carry the can / Clamp the veins / Make the cast / Log the dose / And touch us last.’ While solitary literary production continued, albeit, perhaps, at a different pace, theatre as an art form found itself (yet again) on the brink of disappearance when most venues in the Western world began to close. Theatre became an example of a ‘medical’ phenomenon’s multi-systemic effects: its effects on cultural and artistic production. As in other areas of life, the pandemic drastically exacerbated the already precarious positions of many involved in theatre productions and strengthened numerous systemic inequalities, while it also highlighted the fault lines of the theatre industry. Caridad Svich’s Toward a Future Theatre: Conversations during a Pandemic is a valuable ‘time capsule’ that yields insight into how theatremakers felt at the time: what they feared, hoped, and wished for. Many of the contributors voice the necessity to challenge the supremacist, corporate-modelled, white-capitalist structures that characterize theatre today, to end the erasure, injustice, abuse, perennial (economic, self-) exploitation, rethink the fallible distribution of funding, and take care of its people. Only in this way can theatre become ‘sustainable and accessible – physically, emotionally, financially, creatively, environmentally – for
Zadie Smith, ‘The American Exception’, The New Yorker, April [accessed December ], later published as Zadie Smith, Intimations: Six Essays (London: Penguin, ). Monika Pietrzak-Franger, ‘Covid Knowledge, Transmedia Narratives, and the Poetics of Unreliability in Postdigital Environments’, in Pandemic Storytelling, ed. by Jan Alber and Deborah de Muijnck (Leiden: Brill, forthcoming); Michael Rosen, Many Different Kinds of Love: A Story of Life, Death and the NHS (London: Ebury Press, ). Rosen, p. . Caridad Svich, Toward a Future Theatre: Conversations during the Pandemic (London: Bloomsbury, ), p. . Svich, pp. , .
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Afterword: Literature and Medicine after COVID-
those who make it, and those who engage in it’. Numerous theatre practitioners in Europe openly speak about the ills of contemporary theatre industry and refuse to participate in the neoliberalist mantra of productivity at all costs. In Germany, the Niemand kommt, alle sind dabei (Nobody is coming, everyone is there) festival aimed to raise money for freelance practitioners without offering anything. In Poland, within the framework of the Quarantine Project, a couple of playwrights, Agnieszka Jakimiak and Mateusz Atman, filmed themselves watching their older performances. As they do so, the audiences hear their younger selves criticize the inefficient theatre system; criticism that sounds even more poignant in times of lockdown. Such attempts notwithstanding, many theatres – especially in Great Britain, where, because of sparse support schemes, they are dependent on ticket sales for their survival – offered streaming services of archived material (e.g. the Old Vic’s production of Duncan MacMillan’s Lungs), or new shows, which were especially developed for Zoom (e.g. Big Telly’s Recipe for Disaster). Irrespective of the plays’ varied thematic or aesthetic preoccupations, practitioners and audiences rejoiced at the opportunity of joint, simultaneous, cross-country participation in times of physical distancing. The discourse of community-building was very prominent in this context. Companies such as the US-based Theatre of War Productions, established in , continued their work by employing theatrical means to address social-injustice issues in times of pandemic and climate crisis. Be it their Zoom performance The World on Fire: Ecology, Poetry, and Disability Justice () or their cooperation with the Johns Hopkins Berman Institute of Bioethics and the Johns Hopkins Program in the Arts, Humanities and Health, entitled Theatre of War (), their interventions aim to open dialogue about difficult subjects and ‘foster a sense of connection’.
Svich, p. . Ulf Otto, ‘Post-Performance: Pandemic Breach Experiments, Big Theatre Aata, and the Ends of Theory’, in Presence and Precarity in (Post-)Pandemic Theatre and Performance: Special Issue, ed. by Monika Pietrzak-Franger, Heidi Liedke, and Tamara Radak, Theatre Research International, , (), –. Anna R. Burzyńska, ‘“Close but Far, Human but Square, Normal but Exhausting”: Pandemic Theatre in Poland’, Presence and Precarity in (Post-)Pandemic Theatre and Performance: Special Issue, ed. by Monika Pietrzak-Franger, Heidi Liedke, and Tamara Radak, Theatre Research International, , (), –. Heidi Liedke and Monika Pietrzak-Franger, ‘Viral Theatre: Preliminary Thoughts on the Impact of the COVID- Pandemic on Online Theatre’, Journal of Contemporary Drama in English, , (), –. Theatre of War Productions [accessed January ].
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While theatre attempted to redefine itself as form and practice of community-building for the times of crisis, the novel has been, unsurprisingly, the genre that needed most time to gestate. This said, neither critics nor authors have been particularly enthusiastic about the pandemicthemed novels. Many texts have been described as coming too quickly, as too close to the visceral reality to be palatable, as too makeshift or too refined to harbour the reality-in-the making. Summarizing the tendencies of the new pandemic-themed novels, Alter sees them as trying to ‘capture the texture of daily life in the COVID- era: the corrosive effect of isolation, the tedium and monotony of lockdowns and quarantines, the strain on relationships, the way the virus changed casual interactions and ripped some families apart and brought others together’. This new ‘texture’, though, has brought with itself a number of aesthetic challenges, above all, the reader-deterring grimness of the pandemic plot and the necessity to transform the uneventfulness of the everyday into a compelling narrative. Whereas theatre emphasized the communal experience of watching as conducive to community-building, many novels have focused on the loneliness of individuals in the forced seclusion of the early pandemic. Roddy Doyle’s Life without Children () compiles short stories in which characters struggle with feelings of dislocation and not belonging. The world they describe is full of fractured and disintegrating relationships. ‘If life before the pandemic seemed directionless for the people in these tales,’ argues Malcom Jones, ‘suddenly it is going nowhere even faster’. Similarly, in Sarah Moss’s The Fell (), characters seem encaged in their houses, surrounded by nothing but their own fast-paced thoughts – often, the only interlocutors they have, albeit very unsatisfactory ones. In Sarah Hall’s Burncoat (), the main protagonistsculptor struggles to come to terms both with her past traumas and grievances and with the slow and painful death of her partner. Her unsuccessful attempts at caring for and curing his body as he succumbs to an unknown disease spotlight the meaninglessness of his death: disease transmitted during a burglar’s attack, the effect of a random act of violence by terrified and hungry people. There is little communal spirit in these
Lily Meyer, ‘The Literature of the Pandemic Is Already Here’, The Atlantic, July [accessed December ]. Alter, n.p. Alter, n.p. Jones, n.p. Sarah Moss, The Fell (London: Picador, ).
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novels; instead, secluded individuals neither manage to grapple with the new everyday routines nor do they find much sense in them. These generic transformations and thematic preoccupations are tangible signs of the pandemic’s effects on literature. The narratives that have thus been enabled activate a number of tropes we have become used to. Yet linguistic production has not been confined to established genres. Digital environments have, of course, also had their share in offering new pathways and forms for pandemic imaginaries, irrespective of their positioning on the fact–fiction continuum. Time will tell whether they also offer novel receptacles for an experience that has been so unequal around the globe.
Literature in Times of the Infodemic, Visiodemic, Syndemic Social media platforms have offered spaces for a fast-paced production and circulation of stories of illness by those who either suffered from COVID infection or struggled with Long Covid. As Callard and Perego make clear: ‘Long Covid has a strong claim to be the first illness created through patients finding one another on Twitter: it moved from patients, through various media, to formal clinical and policy channels in just a few months.’ Personal narratives of illness, or ‘autopathographies’ as described by Thomas Couser, began to circulate in such online environments as Twitter or TikTok as well as in blogs, vlogs, podcasts, and on Instagram. These digital spaces have become sites of articulation and exchange and have indubitably shaped the forms of narratives they have produced. The fast-paced reporting during the pandemic has been accompanied by an ‘infodemic’ – an unprecedented spread of (mis)information. The pandemic has been, most frequently, portrayed through specific analogies that have spurred and solidified particular imaginaries. Popular rhetoric has drawn on language that, in addition to revealing old patterns of military
For a list of non-anglophone texts engaging with, among other topics, crime during the pandemic and interconnected social problems, see the research project ‘Corona Fictions’ at the University of Graz: [accessed January ]. Felicity Callard and Elisa Perego, ‘How and Why Patients Made Long Covid’, Social Science & Medicine, (), e (p. ) . Thomas Couser, ‘Autopathography: Women, Illness, and Lifewriting’, a/b: Auto/Biography Studies, , (), – (p. ). WHO, ‘Infodemic’ () [accessed December ].
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metaphors, such as the frequent use of war analogies, also makes clear that the war against the virus is a prolongation of what has been called medicine’s ‘war against ageing and death’. Literary representations of dying during the pandemic will be instrumental for understanding the ways in which we die during COVID- and beyond. While linguistic articulations during the pandemic have received due attention, comparatively little has been said about the accompanying ‘visiodemic’. The term visiodemic highlights the centrality (and the overproduction) of the visual in the global information politics and in the (collective and individual) processes of making sense of the new illness and the pandemic. Maps of symptoms, TikTok posts, or visual metaphors of the ‘we’re in this together’ slogan are but a few of the many examples that have influenced the way we think, talk, and feel about the pandemic. These non-linguistic components of pandemic reporting and fiction along with some illness narratives offer further sites of exploration for scholars wishing to understand the ways in which this global event has impacted our cognition and communication. All these linguistic, visual, digital, and performative productions can be viewed as responses to COVID- and the multifaceted global experiences of illness, pain, dying, lockdown, and quarantine associated with the pandemic. They also allow us to better understand COVID- beyond a narrow framing of it as an infectious disease caused by the SARS-CoV- virus. Richard Horton, The Lancet’s editor-in-chief, revived the notion of a ‘syndemic’, initially coined by the medical anthropologist Merrill Singer, to underline the deep-seated social origins of the pandemic. In Horton’s words, this means that ‘the pursuit of a purely biomedical solution to COVID- will fail’ because such an approach does not address the social
See The Languages of COVID-: Translational and Multilingual Perspectives on Global Healthcare, ed. by Piotry Blumczynski and Steven Wilson (London: Routledge, ). Daniel Callahan, ‘Death, Mourning, and Medical Progress’, Perspectives in Biology and Medicine, , (), – (p. ). Anna M. Elsner, ‘After COVID-: The Way We Die from Now On’, Cambridge Quarterly of Healthcare Ethics, , (), –. Monika Pietrzak-Franger, ‘A “Visiodemic”: COVID-, Contagion Media, and the British Press’, Anglistik, , (), – (p. ) . A particularly strong example of the visual dimension in some of the grassroots responses is the ‘Vitrines en confinement’, [accessed February ], which further exemplify the community-based productions already mentioned. We thank David Houston Jones for alerting us to this project. Richard Horton, ‘Offline: COVID- Is Not a Pandemic’, The Lancet, September [accessed January ]. See also Chapter in this volume for a discussion that engages with the term ‘syndemic’.
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and economic factors behind the pandemic, and disregards their historical roots – roots that are inextricably intertwined with our response to the virus. It has been our contention in this volume that literary and cultural productions are one of the key components that are necessary to understanding medicine, illness, contagion, and – by extension – COVID- as a ‘syndemic’. These productions engage and are interconnected with the socio-economic factors Horton mentions, such as the vulnerability of older citizens, minority ethnic communities, and underpaid healthcare workers. It is therefore not surprising that literary scholars have asserted the need to turn to the humanities to gain a better understanding of COVID-. They have also crowd-sourced COVID- humanities syllabi – in which literary texts as well as literary criticism, such as Priscilla Wald’s seminal work Contagious: Cultures, Carriers, and the Outbreak Narrative (), provide the impetus for reflecting on this global event. They have, finally, also argued for the need to further integrate translational methods into the medical curriculum. Medical historian Molly Worthen opined in The New York Times that ‘the pandemic is a once-in-a-century crisis that may force health professionals and medical schools to look beyond the traditional tools of modern medicine and think more broadly about how we train doctors to grapple with public health catastrophes’. The early months of the pandemic did indeed seem to confirm this: next to the publication of an entire issue of JAMA devoted to narrative medicine, what was to be seen was an increase of humanities courses – in which literature modules play important roles – in medical schools across the US.
Anna M. Elsner and Vanessa Rampton, ‘Science Alone Can’t Solve Covid-: The Humanities Must Help’, Undark, June [accessed January ]. Sari Altschuler and Elizabeth Maddock, ‘Humanities in a Time of Crisis: The Humanities Coronavirus Syllabus’, ISLE: Interdisciplinary Studies for Literature and Environment, , (), –. Kirsten Ostherr, ‘Humanities as Essential Services’, Inside Higher Education, May [accessed January ]. Molly Worthen, ‘A Once-in-a-Century Crisis Can Help Educate Doctors: The Horrors of Covid May Give Proponents of the Liberal Arts an Unexpected Opening’, The New York Times, April [accessed January ]. Altschuler and Maddock, pp. –.
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Literature and Medicine, Quo Vadis? While this volume analyses the literature–medicine interconnection beyond the narrow focus on COVID-, some of the key thematic and theoretical areas discussed across its chapters have been spotlighted by the pandemic and are likely to shape future developments within the field. Although we can briefly touch upon them in the rest of this Afterword, we strongly believe that they need further examination in order to provide a solid foundation for future change. An obvious focus across chapters is put on narratives of care and considerations of social justice in literature across languages and cultures. Who has access to (health)care and who performs (health)care work are but two of many questions that require further attention. Their urgency has been addressed by various essayistic accounts during the pandemic, which drew attention to the manifold personal and social crises of care the pandemic highlighted. These crises spotlight intersectional disparities and signal that further critical engagement with the concept of care, as well as its economic, social, and legal frameworks, is necessary in the field of the medical humanities. Imaginaries of dying and ideals of the good death are likewise among topics that have gained renewed attention throughout the pandemic. Representations of dying have been a vital part of literary texts that engage with the experience of illness and medicine since antiquity, but due to the advances of modern medicine, dying in the West has turned into a drawnout process – with earlier diagnoses and more precise prognoses – that primarily takes place in a medical environment. Narratives engaging with the experience of dying in secularized and medical contexts have grown exponentially; the pandemic and its often lonely deaths as much as the absence of funerals has further stressed the need to scrutinize how medicine is shaping the way we construct stories of dying and what ideals of the good death they rely upon. Due to ageing societies in the West and an increase of neurodegenerative disorders, we have also in recent years seen more personal accounts reflecting on the experience of such diseases in particular. Discussions about ageism and age-related discrimination as part
See Leslie Jamison, ‘When the World Went Away We Made a New One’, The New York Times, May [accessed January ]; Annie Ernaux, ‘Sachez Monsieur le Président. . .’, Radio France, March [accessed January ].
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of COVID- have thus gained further traction. In this context, it would also be important to see them against the tradition of literary depictions of ageing, for instance in Shakespeare’s King Lear or in literary ageing studies, such as Kathleen Woodward’s Ageing and Its Discontents (). The emergence of Long Covid, as previously mentioned, has stressed the necessity to take into account as much the personal as the institutional ‘temporalities of care’ which are, again, often explored and interwoven in personal narratives. Temporalities of illness and medicine are focal points of the chapters of this volume, many of which engage with how temporalities of (chronic) pain have been explored in diverse literary forms and theorized with regard to language more broadly. This preoccupation with chronicity also draws further attention to the necessary exploration of nonnarrative expressions of illness that have become prominent in this context and which are so very central to digital environments. We therefore call for scholars to address these on a more systematic basis. We also believe that the human–animal–environment entanglement should and is bound to be highly relevant, if not central, to the development of the field of literature and medicine post-COVID-. COVID- has highlighted the entanglement of health and nature, an entanglement which has partaken – as the first chapter of this volume shows – in discussions around illness and medicine since antiquity. By having revealed the interconnectedness of human and non-human life forms, the pandemic has not only put a spotlight on science fiction accounts but has also called for a general rethinking of anthropocentric epistemologies in studies of literature and medicine. As the field of planetary humanities develops, its interweaving with discourses of health and medicine seems therefore not only urgent but also unavoidable. As an interdisciplinary field, the medical humanities have assigned a prominent place to literature and medicine since its inception in the s. If we take that position seriously, it is our contention that literary productions from the start have allowed us to show that an understanding of health and medicine cannot operate in a narrow human framework. Concepts such as the ‘posthuman’ and the ‘postnatural’ – which recur in some chapters of this volume – suggest that our understandings of health, medicine, and literature are both entangled and shifting. The field of literature and medicine bears testimony to these various theoretical developments while it also points to its possible postdisciplinary future.
Laura Salisbury, ‘“Between-Time Stories”: Waiting, War and the Temporalities of Care’, BMJ Medical Humanities, , (), –.
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Index
affect, , –, , , , , , , , , ageing, , –, –, , Agrippa Heinrich Cornelius, , Alam, Rumaan, , anatomy, –, , , , anecdote, , , , – Arbuthnot, John, , , –, Aristotle, , , –, ,
cholera, –, choreographies of protest, , , – Christ, –, , –, chronic pain, , , , –, , , , , , , , coils, , –, collaboration, xv, , , , , , colonialism, , , , comics, , , – contagion, , , , , –, , –, , –, , –, , , contemporary literature, , Cooper, Melinda, – COVID-, , , , –, , , , , , –, , , , , , –, – critical medical humanities, , , , , , , , –, – cryonics, , , –, –
Bandyopādhyāy, Tārāshankar, – Bardes, Charles, –, Bengali literature, , –, –, , , – Berkowitz, Amy, , –, Bharucha, Rustom, –, bias, , , , , , bibliotherapy, bioethics, , , –, , – Bion, Wilfred, –, , Biss, Eula, , , –, Blackmore, Sir Richard, –, –, , Book of Margery Kempe, , , , Boyer, Anne, –, , , , – Brown, Laura, – Broyard, Anatole, , , – Burton, Robert, – Caduff, Carlo, , , , Callard, Felicity, , , Camus, Albert, , , cancer, , , , , , , –, , , , , , , –, , , , –, caregiving, –, –, , caricature, Carrère, Emmanuel, – Caruth, Cathy, , –, , Charon, Rita, , , , , , –, , , ,
D’Israeli, Isaac, , Daniel, Henry, – de Ahumada of Avila, Teresa, , de Balzac, Honoré, , de Kerangal, Maylis, , , – DeLillo, Don, , , , dementia, , , , –, –, – Dickens, Charles, – digression, , disability, , , –, , , , , , –, , Donne, John, , Dryden, John, , du Laurens, André, , Eliot, George, , , empathy, , , , , , , , , –, –, epidemic, , –, , , –, , , , , , , –, episodicity, , –, , ,
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Index essay, , , , , , –, , , , , , , ethics of care, , , , , – Ferrante, Elena, , , –, – Fleming, Paul, , , Foster, Susan Leigh, – Frank, Arthur, , , , , Freeman, Mark, , , , Freud, Sigmund, –, , –, Galen, , , Garner, Stanton B., –, Garth, Samuel, , –, Gaskell, Elizabeth, , gender, , , , , , , , germ theory, , , , , Gleeson, Sinéad, , – Goffman, Erving, , , graphic medicine, , , , –, – Green, Michael J., – Guibert, Hervé, , , , , , –, guts, , , , – Harvey, William, –, , , Heller, Joseph, – Hippocrates, , , HIV-AIDS, , – Holt, Anne, –, Homer, –, Huber, Sonya, , , , – human capital, –, , humanism, , , , , , , Iacub, Marcela, , , identity, , , , , , , , , , , , , , , , , , –, , , , , , , , illness narrative, , , , , , –, , , –, , , , , , interdisciplinarity, , , , , intestines, –, – James, Henry, , , Kalanithi, Paul, , –, Keats, John, , –, , Kempe, Margery, , – Kleeman, Alexandra, – Kuusisto, Stephen, –, Lancaster, Henry of, – Laurens, Camille, , ,
Levin, Leonard, literary realism, , –, , Lock, Margaret, , Lorde, Audre, , – Luckhurst, Roger, – Lyotard, Jean-François, , Martini, Clem, – Martini, Olivier, – masculinity, , , , Mattingly, Cheryl, – McCarthy, Cormac, , McCloud, Scott, , McCully Brown, Molly, , medical education, , , , , , , , , , , , medical humanities, , , , , , –, , , , , –, –, , , , –, – medieval medicine, , , , melancholy, –, memoir, , , , , , , , , , –, mental breakdown, , , – Mitchell, Wendy, –, – modernism, , , Morrison, Toni, , – Mukhopādhyāy, Trailokyanāth, , –, Napier, Richard, – narrative medicine, , , , , , , , , –, –, –, , , , , , , , Nightingale, Florence, , , Noe, Matthew, nutrition, , , , , Olstein, Lisa, , , –, Osler, Wiliam, , , – outbreak narrative, , , parallel chart, , – pathography, , , , , , , , –, patient, –, , , , , , , , , , , –, –, –, , –, , , , , –, –, , , , , , , , –, , , , –, , –, , , , –, , , , , , –, , , , patient’s story, , , , , , , performance, , , , –, , , , –
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Index
philosophy, , , , , , , , –, –, , , physician, , , –, , , , –, , –, , , , , , , , , , , –, , , , , –, , –, , , , , , –, , , – Plato, – poetry, , , , , , , , –, , –, –, , , , , , politics, , , , , , , , , , , , , , , Pontalis, Jean-Bertrand, –, posthumanism, , , postmodernism, , , postnatural death, , , , Post-Traumatic Stress Disorder, , –, , , , – poverty, , , , , –, , , – Procopius, – Professional Identity Formation, – psychic pain, , –, psychoanalysis, , , –, , –, , Quayson, Ato, , , Ray, Annadāshankar, , , Ross, Ronald, –, Sacks, Oliver, , – Sartwell, Crispin, , – Scarry, Elaine, , Schwager, Susanna, , – sensation, –, , , , , , , –, , , Shorter, Edward, Singer, Merrill, , –, Small, Helen, , , Snow, John, , , Sontag, Susan, , , , , , , St. John Mandel, Emily, ,
stomach, –, , , , , Strawson, Galen, , , symptom, –, –, , –, , –, , , , , , , , , , , , , , –, , , , syndemic, , , , –, , Tagore, Rabindranāth, –, , , – testimony, , , , , , , , , , the body, , –, , , –, –, , , , –, , , , , , , –, , , , , , –, , , , , , , , , the self, , , –, , , , –, , , , , Thompson-Spires, Nafissa, , Tolstoy, Leo, , , , , , transhumanism, , , , transplantation, –, , , Tronto, Joan C., , , , trust, , , , , , , , , , , twentieth-century literature, , , , violence, , , , , , , , , , , , , , viral performance, – vitalism, –, , Wald, Priscilla, , –, Waldby, Catherine, – Wasson, Sara, , , Weyer, Johann, , – Whitehead, Anne, Williams, Ian, –, , , Williams, William Carlos, –, , Willis, Thomas, –, Woolf, Virginia, , , , – working-class, , , , , , , ,
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